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* 1. Please indicate Date of DAISY Nomination

Date

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* 2. Submitter's Name

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* 3. Tell us about you.

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* 4. Please share your email address.

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* 5. Please share your phone number.

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* 6. Nurse's Name

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* 7. Nurse's Unit or Department

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* 8. Please describe a specific situation or story that demonstrates how this nurse made a meaningful difference in your care.

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* 9. If the nurse is awarded the DAISY Award for EXTRAORDINARY Nurses, you would like to be a part of the celebration.

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* 10. By selecting Yes and submitting this online form, you agree to The DAISY Foundation and/or its partners collecting and storing the information you submit, including your personal contact information, in accordance with the DAISY Foundation Privacy and applicable law. The DAISY Foundation or the organization where your nurses works may contact you with questions about your submission.

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