WISCONSIN ASSISTED LIVING NOMINATION FORM Question Title * 1. I am nominating a: Caregiver (includes medication assistants) Team Member (defined as non-caregiver, non-manager) Department Director Executive Director Question Title * 2. Region: Northern Wisconsin Northeast Wisconsin South Central Wisconsin Southeast Wisconsin West Central Wisconsin Question Title * 3. Please provide the following information Nominee's Name Nominee's Title Community Your Name Your Title Your Email You Phone number Question Title * 4. How long has the nominee: Worked for your company Worked in senior living Question Title * 5. Tell us about a specific time when the nominee went above and beyond day-to-day responsibilities and demonstrated an exceptional commitment to residents. Question Title * 6. Provide an example of actions taken or attitudes displayed by the nominee that have enhanced residents’ quality of life. Be specific. Question Title * 7. Provide an example of how the nominee has been a positive influence on residents and/or fellow staff. Question Title * 8. What do you consider to be the nominee's greatest WOW factor? Provide an example in which this was demonstrated. Question Title * 9. Tell us how the nominee has advanced the mission and goals of the community. Question Title * 10. Give an example of how the nominee has positively influenced/impacted the overall community culture and/or the community-at-large. Question Title Done