Caregiver Nomination Form
The purpose of the Hope After Loss Compassionate Care Award is to recognize and promote excellence in the care of families who have lost a pregnancy or infant. All healthcare providers in the state of Connecticut are eligible to be nominated by someone who has suffered a loss in the past three years. Every nominator may nominate multiple people in a group or institution but may submit only one nomination per year. Nominators must be willing to attend the Compassionate Care Awards on May 6, 2020 should their nominee(s) be selected as a recipient of the award.
Nominator Name (your name) *
Your answer
Nominator Email (email you would prefer to be contacted by Hope After Loss) *
Your answer
Nominator Phone Number (phone number you would prefer to be contacted by Hope After Loss) *
Your answer
Nominee Profession (profession of the person you are nominating) *
Nominee Name (Person or group you are nominating) *
Your answer
Nominee Place of Business *
Your answer
Nominee Place of Business Address *
Your answer
Nominee Email
Your answer
Nominee Phone Number *
Your answer
Please describe the type of loss(es) you have experienced and when those losses occurred. (150 words) *
Your answer
Why are you nominating this caregiver for the 2020 Compassionate Care Award? (150 words) *
Your answer
Please provide a quote about why you believe compassionate care is important when it comes to caring for patients experiencing pregnancy and/or infant loss. (50 words) *
Your answer
Can you describe a specific action or expression of compassion that you appreciated receiving from your caregiver(s)? (150 words) *
Your answer
Please describe something your caregiver did that you wish all caregivers knew to do with their patients. (150 words) *
Your answer
May we share parts of your story in materials such as press releases and event collateral and use your name? *
May we share your submission with the person/group you have nominated? *
Should your nominee(s) be selected, are you available to attend the Compassionate Care Award event at 6PM on May 6, 2020 at Woodwinds in Branford, CT? *
Possible Conflict of Interest: Do you know of any possible conflicts of interest related to your nomination? Conflicts may include the NOMINATOR or NOMINEE being a 2020 Event Sponsor, a staff member, a current Director of the Hope After Loss Board or a member of the 2020 Compassionate Care Awards Planning Committee. IF THERE ARE NO KNOWN POSSIBLE CONFLICTS, PLEASE WRITE "NONE" *
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Hope After Loss, Inc.. Report Abuse