Gold Standard Award: Nomination Form

Gold Standard Award: Nomination Form

The HCHB Gold Standard Award recognizes individual clinicians promoting clinical excellence within their organization. It celebrates individuals who utilize HCHB to deliver exceptional patient care.

Learn more about our HCHB Gold Standard Awards here.

Nominator Information

Nominator's Full Name*

First and Last Name

Nominator Email Address*

Nominee Information

Nominee Name*

First & Last Name

Nominee Job Title*

Nominee Email Address*

Agency Name*

Reason for Nomination*

Share your nominee's contributions in promoting clinical excellence within your organization through the effective use of HCHB to provide outstanding patient care.

Leadership Contact Information

Manager First & Last Name*

We will include the manager on any communication sent to the nominee/winner.

Manager Email Address*

Additional Contact First & Last Name

If you want to include an additional manager or contact in the communication, please provide their information.

Additional Contact Email Address

Release of Information

Opt In for Permission*

If my nominee is selected for the Gold Standard Award, I release and grant Homecare Homebase authorization to reproduce, copyright, exhibit, broadcast, electronic storage and/or distribution of said text/photographs/film/video tapes/electronic representations, and/or sound recordings without limitation at the discretion of Homecare Homebase. I specifically waive any right to any compensation I may have for any of the foregoing.

Company Description/Boilerplate

Brief company description to be in a press release if your nomination is selected.

Company Website Link

Include the link to your company's website.

Send me a copy of my responses

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