Physician Award Nomination Form

Purpose: To recognize and award any Physician within our NCH system, who exemplify the conditions for each award listed below.

Eligibility: Any physician with active privileges at Northwest Community Hospital.

Process: Any employee, patient, physician or volunteer may nominate. Recipients will be selected on the basis of evidence provided by completion of the nomination eligibility criteria.

Award: The award winners will be announced later this year.

Nominations accepted through November 25, 2020.

Nominee Name*

Nominee First Name* Nominee Last Name*

Check the box next to the award for which you are submitting a nomination:*

Leadership Award - Honors physicians who have made a positive difference in one or more of the following: quality outcomes, safety, patient experience or service development as evidenced by hours of service, outcomes achieved, a change in process achieved, and/or a new policy or practice implemented. (formal leadership title not required)

Humanitarian Award - Honors physicians who have made an outstanding humanitarian contribution in the medical field.

NCH Values Award - Honors physicians who live out the NCH Values of Compassion, Commitment, Excellence, Integrity, Collaboration, or Advancing knowledge.You can nominate a physician for each value.

Supporting information for your nomination:*

Your Name*

Your First Name* Your Last Name*

Your Email*

Your Phone*

*Required Field

Physician Award Nomination Form

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