Maine Hospital Association - Caregiver of the Year Nomination Form

Nominee's Name:

Nominee's Title :

Hospital:

Nominee's Email:

Nominee's telephone number:

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Nominee's address 1:

Nominee's address 2:

City :

State:

U.S. ZIP code:

Nominator's Name:

Nominator's Title:

Nominator's Email:

Nominator's telephone number:

( ) -

Nominator's Company or Hospital:

Nominator's address 1:

Nominator's address 2:

City:

State:

U.S. ZIP code:

Why should this person be Caregiver of the Year:

Please briefly describe (500 words or less) how the nominee demonstrates the criteria set forth in this award and as such is deserving of the award. Nominees should demonstrate the following characteristics: 1) exemplifies extraordinary commitment to patients on a daily basis; 2) shows compassion, empathy and respect in the delivery of care to patients and their families; 3) acknowledges and meets the unique physical, emotional and practical needs of patients and their families; and 4) promotes an environment of cooperation and collaboration in which the expertise and experience of all healthcare professionals are available to patients. You can cut and paste from a word processing program, or you can upload your essay and any supporting material below.

Example 1:

Please cite example one of at least two specific examples of how the nominee has gone “above and beyond the call of duty” in demonstrating extraordinary commitment to patient care.

Example 2:

Please cite the second of at least two specific examples of how the nominee has gone “above and beyond the call of duty” in demonstrating extraordinary commitment to a patient care.

Example 3:

Please cite a third specific example, if you have one, of how the nominee has gone “above and beyond the call of duty” in demonstrating extraordinary commitment to patient care.

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