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Test form - Innovation
Nomination Form - Innovation
Your Information:
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indicates required fields
Click here
to see how we may share your nomination.
If you would like to save and continue the nomination later, please click the 'Save and Continue Later' button at the bottom of the form.
This will display a page with the link to use to continue your submission.
Enter your email address and click 'Send Link' to have the link sent to you in an email.
Without this link it is not possible to resume your submission.
Your Name
*
Today's Date
*
MM slash DD slash YYYY
Your Position Title
*
Your state
*
Select:
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Texas
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Washington
Wisconsin
National System Teams
Other
Your email address
*
Your Nominee:
Nominee Position (select from dropdown)
*
Select:
Leader (Director and Above)
Provider (Physician or APP / APC - e.g., Nurse Practitioner, Physician Assistant, Nurse Midwife)
Staff Member
Team / Department
Upload a list of email addresses:
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Accepted file types: txt, pdf, xls, doc, docx, Max. file size: 50 MB.
Nominee Name (Search Nominee Formal Last Name)
*
Nominee email address
*
Facility Address (if working remotely, enter "remote")
*
Facility Name (if working remotely, enter "remote")
*
Department
Nominee state
*
Select:
Arizona
Arkansas
California
Colorado
Georgia
Illinois
Indiana
Iowa
Kansas
Kentucky
Minnesota
Nebraska
Nevada
New Mexico
North Dakota
Ohio
Oregon
Pennsylvania
Tennessee
Texas
Utah
Washington
Wisconsin
National System Teams
Other, please enter below
Other state
*
Please do not include any patient identifiable information in the submission.
How does the nominee meet the criteria (below) for their nominated category? (Max: 800 characters)
*
Name
This field is for validation purposes and should be left unchanged.
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