Distinguished Service AwardsNomination Form 2024

Nominator's Name*

Nominator Facility*

Nominator's Email*

Nominator's Phone*

Nominee's Name*

Nominee's Facility*

In 500 words or less, describe current or recent circumstances where this individual has gone above and beyond in making a contribution to or demonstrating a high level of commitment towards advancing a healthy community or the mission of their facility.*

Note: "Community" means locally (within their facility or community), regionally or on a statewide-level.

In 500 words or less, describe how this individual demonstrates leadership and passion in the advancement or promotion of quality health care in their community or in the state.*

In 500 words or less, describe evidence of this individual's heightened involvement in addressing health care needs within their community/facility (or statewide, if applicable).*

Will you be submitting any testimonial letters?*

You can upload below or you can send them to info@sdaho.org. Please include the nominee's name in the file name. For example: JaneDoe_YoungProfessional.doc.

Yes

No

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