2020 WISCONSIN ASSISTED LIVING NOMINATION FORM

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* 1. I am nominating a:

Outstanding Caregiver

Outstanding Team Member (maintenance, cook, nurse, life enrichment, etc.)

Outstanding Department Head

Outstanding Executive Director/Administrator

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* 2. Region:

Northern Wisconsin

Northeast Wisconsin

South Central Wisconsin

Southeast Wisconsin

West Central Wisconsin

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* 3. Please provide the following information

Nominee's Name

Nominee's Title

Community

Your Name

Your Title

Your Email

You Phone number

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* 4. How long has the nominee:

Worked for your company

Worked in senior living

Narrative Section—use all the space you need to respond to the narrative questions.

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* 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.

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* 6. Provide an example of actions taken or attitudes displayed by the nominee that have enhanced residents’ quality of life. Be specific.

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* 7. Provide an example of how the nominee has been a positive influence on residents and/or fellow staff.

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* 8. What do you consider to be the nominee's greatest WOW factor? Provide an example in which this was demonstrated.

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* 9. Tell us how the nominee has advanced the mission and goals of the community.

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* 10. Give an example of how the nominee has positively influenced/impacted the overall community culture and/or the community-at-large.

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