Dell Children's Medical Center DAISY Nomination

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Want to Say Thank You to Your Nurse?

Share your story!

The family of J. Patrick Barnes started the DAISY (Diseases Attacking the Immune SYstem) Foundation in his memory. Patrick developed ITP, an auto-immune disease, but sadly died from his illness in 1999. The nurses made a big difference while Patrick and his family were in the hospital. His family was so grateful for the care he received that they created the DAISY Award. The Award is a way to thank your nurse and celebrate the wonderful care they give every day.

Please share your story and tell us how a nurse made a difference for you!

Your Name:

Your Email:

Date

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M-D-Y

I am a (please check one):

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I learned how to thank my nurse with a DAISY Award nomination from:

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A nurse or staff member

A nurse manager or supervisor

A flyer in the hospital

A DAISY nomination QR card provided to me

other

Which Dell Children's Campus does this nurse or team of nurses work at?

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NOTE If you are not a patient or family member and are submitting a DAISY nomination for a nurse or nursing team, please ensure you do not include any Protected Health Information (PHI) in your nomination.

This nomination is for:

one (1) nurse

a team of two (2) or more nurses

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Name of your nurse:

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Names of the nurses on your team: (List each name: Nurse 1, Nurse 2, Nurse 3, Nurse 4, etc.)

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Dell Children's Campus where your nurse works:
Central (4900 Mueller Blvd. )
OR
North (9010 N. Lake Creek Parkway)

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Dell Children's Campus where your nursing team works:
(Central or North)

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Unit where your nurse works:

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Unit where your nursing team works:

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By telling my story, I understand it may be shared in print or on the internet if my nurse is selected as a winner of The DAISY Award.
Your Signature:

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I would like to thank my nurse because:

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I would like to thank my nursing team because:

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Dell Children's Medical Center DAISY Nomination

** NOTE ** If you are not a patient or family member and are submitting a DAISY nomination for a nurse or nursing team, please ensure you do not include any Protected Health Information (PHI) in your nomination.

You have selected an option that triggers this survey to end right now.

NOTE If you are not a patient or family member and are submitting a DAISY nomination for a nurse or nursing team, please ensure you do not include any Protected Health Information (PHI) in your nomination.