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* 1. Who are you nominating? (list individual name(s), department, or team)  

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* 2. Enter the facility name.

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* 3. Select the award category.

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* 4. How has your nominee demonstrated their commitment to improving patient safety? Considerations for the narrative:
  1. 500 words or less 
  2. Do not include any identifiable information, e.g., organization name, patient information.

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* 5. Who will serve as the primary point-of-contact, e.g., Patient Safety Officer, Director of Nursing, Communications Director, etc.?

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* 6. How can we contact you if follow-up is needed?

Prior to hitting submit, please double-check your nomination for accuracy. You cannot make changes to your entry beyond this point.

Nominations will be accepted through December 10, 2021!  

Thanks for taking the time to recognize this outstanding commitment to patient safety.

Forward questions, comments, or concerns to Heather Stone at heatstone@pa.gov.

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