The DAISY Award for Extraordinary Nurses Nomination Form

Thank you for taking the time to nominate an extraordinary nurse for this award.

The DAISY (Diseases Attacking the Immune SYstem) Award is an international recognition program that honors and celebrates the skillful, compassionate care nurses provide every day. The DAISY Foundation was established by the family of J. Patrick Barnes after he died from complications of the auto-immune disease ITP in 1999. During his hospitalization, they deeply appreciated the care and compassion shown to Patrick and his entire family. When he died, they felt compelled to say "thank you" to nurses in a very public way. Please say thank you by sharing your story of how a nurse made a difference you will never forget!

Question Title

* 1. Your Contact Information:

Name

Email Address

Phone Number

Question Title

* 2. I am (please check one):

Patient

Family/Visitor

Other (please specify)

Question Title

* 3. Would you like to be notified if your nurse is chosen as a DAISY Honoree so that you may attend the celebration if available?

Yes, please.

No, thank you.

Question Title

* 4. Name of the nurse you are nominating:

Question Title

* 5. Department/Unit/Clinic where this nurse works:

The nominee consistently meets all of the following criteria (PETALS):

P - Passion/compassion for nursing and the care you provide
E – Empathy in the situation
T - Trust and Teamwork of families, patient and peers
A – Admirable attributes possessed
L – Love for the patient and nursing profession
S – Selflessness

Question Title

* 6. Please describe a specific story or situation involving the nurse you are nominating that clearly demonstrates how he/she meets the criteria for the DAISY Award:

Each DAISY Award Honoree will be recognized at a public ceremony in her/his unit and will receive: a beautiful certificate, a DAISY Award pin, and a hard-carved stone sculpture entitled A Healer's Touch. Additionally, everyone in the unit will celebrate with cinnamon rolls - a favorite of Patrick's during his illness. The Barnes Family asks that whenever and wherever nurses smell that wonderful cinnamon aroma, they stop for a moment and think about how special they are.