2021 Nomination Form – The Schwartz Center

2021 National Compassionate Caregiver of the Year^® Award Nomination Form

Step 1 of 2

Your Information
Please tell us about yourself.
Your Name*
Prefix First Last Suffix
Your Organization
Your Email Address*
Your Email Address Confirm Your Email Address
Your Phone Number*
Your Address*
Your Street Address Your Street Address Line 2 Your City Your State / Province Your Zip / Postal Code Your Country
How did you hear about the award?*
Nominee
Individual Nominee Information
Please enter the caregiver's information.
Nominee's Name*
Prefix Nominee's First Name Nominee's Last Name Nominee's Suffix
Nominee's Profession*
Nominee's Other Profession*
Nominee's Organization*
Nominee's Email Address*
An accurate email address for your nominee is important. All nominees will be notified using the email address you provide for them. The Schwartz Center will email your nominee a link to the form they need to complete in order to be considered for the 2021 NCCY Award.
Nominee's Email Address Confirm Nominee's Email Address
Nominee's Phone Number*
Nominee's Address*
Nominee's Street Address Nominee's Street Address Line 2 Nominee's City Nominee's State / Province Nominee's Zip / Postal Code Nominee's Country
Team Nominee Information
Please enter the caregiving team’s information.
Team's Name*
Team's Organization*
Is this team composed of a multidisciplinary group of 3+ individuals working together on an ongoing basis?*
- Yes
- No
Teams must be a multidisciplinary group of 3+ individuals working together on an ongoing basis. If you have any questions, please contact us at nominations@theschwartzcenter.org.
Would you like to identify additional members of this care team at this time?
- Yes
- No
Additional Team Member(s)
Please list additional team member names below, separated by commas.
Team Leader
We require the name and contact information of one team member to serve as the team leader for the purpose of this award. Due to the volume of nominees, we rely on the team leader for all award communications.
Team Leader's Name*
Team Leader's Prefix Team Leader's First Name Team Leader's Last Name Team Leader's Suffix
Team Leader's Profession*
Team Leader's Other Profession*
Team Leader's Email Address*
An accurate email address for the team leader is important. All team leaders will be notified using the email address you provide for them. The Schwartz Center will email the team leader a link to the form they need to complete on behalf of their team in order to be considered for the 2021 NCCY Award.
Team Leader's Email Address Confirm Team Leader's Email Address
Team Leader's Phone Number*
Team Leader's Address*
Team Leader's Street Address Team Leader's Street Address Line 2 Team Leader's City Team Leader's State / Province Team Leader's Zip / Postal Code Team Leader's Country
Individual Nomination Question 1 (required)*
What does compassionate care means to you?
Individual Nomination Question 2 (required)*
How does your work support the well-being of patients and their families? How do you demonstrate compassion to the populations you serve? Please provide examples.
Individual Nomination Question 3 (required)*
How has your work contributed to (or aligned with) one or more of the NCCY Areas of Impact? Please provide examples.
Individual Nomination Question 4 (optional)
Have you developed or implemented (or helped to develop or implement) an innovative program, practice, or policy that has had a meaningful impact on healthcare experiences and/or outcomes?
Individual Nomination Question 5 (optional)
Have you developed or implemented (or helped to develop or implement) an innovative program, practice, or policy that has enabled equitable access to compassionate, high-quality healthcare for underserved communities?
Team Nomination Question 1 (required)*
What does compassionate care means to you and your team?
Team Nomination Question 2 (required)*
How does your team's work support the well-being of patients and their families? How does your team demonstrate compassion to the populations you serve? Please provide examples.*
Team Nomination Question 3 (required)*
How has your team's work contributed to (or aligned with) one or more of the NCCY Areas of Impact? Please provide examples.
Team Nomination Question 4 (optional)
Has your team developed or implemented (or helped to develop or implement) an innovative program, practice, or policy that has had a meaningful impact on healthcare experiences and/or outcomes?
Team Nomination Question 5 (optional)
Has your team developed or implemented (or helped to develop or implement) an innovative program, practice, or policy that has enabled equitable access to compassionate, high-quality healthcare for underserved communities?

2021 National Compassionate Caregiver of the Year® Award Nomination Form

Step 1 of 2

Your Information

Nominee

Individual Nominee Information

Team Nominee Information

Team Leader

Confirmation

2021 National Compassionate Caregiver of the Year^® Award Nomination Form