Thank you for your interest in nominating a nurse for the DAISY Award. Please
complete the nomination form and use the directions below to submit the
nomination.
Directions:
1. Complete the nomination form.
2. Send the completed nomination via:
Mail:
PSA Healthcare
7602 Bridgeport Way West, Suite 2B
Lakewood, WA 98499-2415
Attn: Leslie Elder
Fax:
(253) 912-4862
Attn: Leslie Elder
Email: preferred (put the PSA location in the subject line)
[email protected]
Give to the CCM for delivery
Daisy Award Nomination Form
I nominate _________________________________ from the ____________________ location as a
worthy recipient of The DAISY Award. This nurse exemplifies quality nursing care that patients, families, or
PSA Healthcare staff recognize as an outstanding role model and patient advocate. This nurse exhibits the
following highly valued qualities and skills that promote PSA Healthcare’s mission of providing Trusted
Care:
Taking Action
Giving Care
Building Trust
Positive energy
Sense of urgency to act
Improves patient/family experience
Above/beyond the call of duty
Caring
Timely/Detailed/Accurate
Leadership/Mentoring
Improves outcome/experiences
Integrity
Courage
Dependability
Honesty
Please use the above criteria to describe why this nurse should receive the DAISY Award. Please consider
adding examples on how this nurse provides quality nursing care by Taking Action, Giving Care and
Building Trust.
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Daisy Award Nomination Form •1 _____________________________________________________________________________________
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Name of person submitting the nomination: ____________________________________
(Printed name)
____________________________________
(Signature)
________________________________________
(Date)
How can we contact you? ____________________________________
Daisy Award Nomination Form •2 --------------------------------------------------------------------------------------------------------------------For internal use
--------------------------------------------------------------------------------------------------------------------Sent to: _____________________________________Date:____________________
Location Director
A check in this box signifies that this nominee is in good standing within the
Organization and you support the nomination.
(good standing = not on probation, employed, not on administrative leave, etc.)
Name:_______________________(printed)_________________________(signed)____________(date)
Return this nomination to [email protected] IMPORTANT—list the PSA location and
DAISY Award in the subject line in the email.
You can also follow the delivery instructions on the first page of this form. Email is preferred
--------------------------------------------------------------------------------------------------------------------For nominating committee review:
Assigned number: Received:
Sent to committee member/date:
Recommendation:
Director notified of result:
Sent back to Leslie (date):
Letter/nominee pin
Winner/award packet
Beth notified to generate certificate/mail box:
Daisy Award Nomination Form •3