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DAISY Award Nomination Form
VA Central California Health Care System
Use this form to recognize a nurse who has gone above and beyond to make a difference.
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1.
Employee's name:
(Required.)
2.
Employee's unit or job:
3.
This nomination is for
LVN (Licensed Vocational Nurse)
RN (Registered Nurse - Inpatient or Outpatient)
APRN/NP/CRNA (Post-Graduate Nursing Positions)
Nurse-Led Team (Any team within the health care system led by a nurse at any level)
Nurse Leader (Nurse Manager, Assistant Nurse Manager, Chief Nurse, Associate Chief Nurse, DADPCS, ADPCS)
Lifetime Achievement (Recognizes the legacy of 25+ years of service)
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4.
Please tell us how this nurse demonstrated at least one of VA's I CARE values:
Integrity:
Maintains the trust and confidence of all with whom she/he engages.
Commitment:
Serves Veterans and their families by honoring the VA’s mission.
Advocacy:
Truly focuses on serving the Veteran.
Respect:
Provides dignity and respect to everyone she/he serves and encounters.
Excellence:
Strives for the highest quality and continuous improvement.
(Required.)
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5.
Please share your story of what this nurse's actions meant to you
(250 words or less):
(Required.)
6.
Please tell us your name.
*
7.
Choose the role that best describes you:
(Required.)
Patient
Family member
Caregiver
Employee
Other (please specify)
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8.
How you would like to be notified if the employee you are nominating is selected for a DAISY Award?
(Required.)
I don't want to be contacted.
I want to be contacted.
9.
Nurses who are nominated receive an official DAISY nomination certificate, a DAISY Nominee pin, a copy of your nomination, cinnamon rolls, and an in-person celebration on their unit with hospital leadership. All other staff who are nominated are submitted for VACCHCS Incentive Awards and receive a certificate and promotional item and are invited to receive their awards at the in-person hospital-wide monthly Incentive Awards ceremony.
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