2022 Trauma Award Nomination Form

Excellence in Trauma Care Award Nomination

o This award honors a Trauma Provider who is/has been exemplary in his or her quality of patient care and/or dedication to his/her community. This is a person who has consistently exhibited dedication to the trauma system through excellent patient care and a commitment to trauma education, injury prevention, or community awareness.

o This may be a past or present trauma nurse or provider, Trauma Coordinator, Trauma Medical Director, Trauma Registrar, or Injury Prevention Coordinator.

o 2 awards will be presented

NOMINATIONS MUST BE RECEIVED BY 5:00PM, AUGUST 5, 2022.

Question Title

* 1. Nominee Information

Name

Facility

Address

Email (if known)

Question Title

* 2. Contact Information for person making nomination

Name

Phone Number

Question Title

* 3. Reason for Nomination
Please include nominee's trauma background, reason for nomination and contribution/impact on the trauma system locally, regionally and/or state-wide.

2022 Trauma Award Nomination Form

Excellence in Trauma Care Award Nomination

Question Title

* 1. Nominee Information

Question Title

* 2. Contact Information for person making nomination

Question Title

* 3. Reason for NominationPlease include nominee's trauma background, reason for nomination and contribution/impact on the trauma system locally, regionally and/or state-wide.

* 3. Reason for Nomination
Please include nominee's trauma background, reason for nomination and contribution/impact on the trauma system locally, regionally and/or state-wide.