The DAISY Award for Extraordinary Nurses Nomination Form

KAISER PERMANENTE - RWC

The DAISY Award is an international recognition program started in memory of J. Patrick Barnes. Pat’s family experienced first-hand the difference his nurses made in his care through clinical excellence and outstanding, compassionate care. The family created The DAISY Award to express gratitude to nurses and to enable other patients, families, and staff to thank and honor their special nurses.

Please visit DAISYFoundation.org (https://www.daisyfoundation.org/) to learn more about Pat's story and how The DAISY Award recognizes Extraordinary Nurses.

Complete this form to share your story of how a nurse made a difference in your care or that of someone you know.

Thank you for taking the time to thank your nurse! Please enter detailed information.

Sample Nomination Story:

"Our 88-year-old mother was a patient for 2 weeks. Mom was on a roller coaster, we never knew what to expect. Everything was new and frightening to us as we watched her struggle to live. Through it all, Tami was there, working tirelessly, diligently, helping Mom and us understand issues and ramifications. She patiently explained things to us, sometimes more than once, until we got it. Of utmost importance to her was Mom's comfort. Tami was also concerned about each of us as we went through our own emotional and exhausting roller coaster rides. We looked forward each day to seeing Tami. She obviously cared deeply for Mom. Tami became like family. I wanted to hug her hello and goodbye. Everyday her knowledge and skills were evident. Such as, for 1 tiny example, the day 02 saturation was dropping, chest tubes were in-Tami analyzed the best position to put mom into with those tubes in order to maximize 02 saturation. It worked. Tami's tireless, devoted, and skilled passion for our mother's well-being made a huge impression on us. She stood out as a nurse willing and able to go beyond the normal call of duty."

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* 1. Your Contact Information please

Name

Email Address

Phone Number

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* 2. Please contact me if my nurse is chosen so that I may attend the celebration if available.

Yes

Maybe

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* 3. I am

Patient

Staff

Volunteer

Family/Visitor

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* 4. Date of Nomination

Date

Date

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* 5. What is the first name and last name of the nurse or nurse leader you are nominating? If this is a Teams Award, list all the FULL names.

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* 6. Is this nurse Full time Employee in Kaiser RWC or is a traveler.

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* 7. Is this nurse Full time Employee at Kaiser RWC or a traveler.

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* 8. Please describe in DETAIL a specific situation or story that clearly demonstrates how this nurse made a meaningful difference in your care. (See example story shown as "Sample Nomination Story" in the beginning.