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Please complete all boxes to tell us how you intend to implement The DAISY Award program.

VERY IMPORTANT: Please inform your IT Department to allow all emails from DAISYFoundation.org to reach you as most of our communication is via email.

About Your Organization

Your institution/facility (as you would like it listed on our website roster):

Healthcare system, if applicable:

Do you have shared governance in your organization?

Are you a Magnet-designated organization?

Are you a Pathway to Excellence-designated Organization?

Approximate number of nurses: (please use numbers only, with no dashes or text)

Approximate number of beds: (please use numbers only, with no dashes or text)

Your organization's website: (www.yourwebsite.org):

Multiple Facility Information

Will you have multiple facilities or locations participate in your DAISY Award program? (e.g. hospitals, ambulatory care facilities, clinics, etc.)

Type of Location(s) Participating (hold Ctrl key for multiple selection):

Number of Additional Locations Participating:

Location 1 Multiple Facility Information

Please enter location information for all of your participating locations below. This will ensure that your patients or their families will be directed to you if they wish to nominate one of your nurses using our website. If you have this information on a spreadsheet and would prefer to attach that, please change your selection above to "spreadsheet". Thank you!

Name of facility:

City:

State, if in USA:

Location 2 Multiple Facility Information

Name of facility:

City:

State, if in USA:

Location 3 Multiple Facility Information

Name of facility:

City:

State, if in USA:

Location 4 Multiple Facility Information

Name of facility:

City:

State, if in USA:

Location 5 Multiple Facility Information

Name of facility:

City:

State, if in USA:

Location 6 Multiple Facility Information

Name of facility:

City:

State, if in USA:

Location 7 Multiple Facility Information

Name of facility:

City:

State, if USA:

Location 8 Multiple Facility Information

Name of facility:

City:

State, if in USA:

Location 9 Multiple Facility Information

Name of facility:

City:

State, if in USA:

Location 10 Multiple Facility Information

Name of facility:

City:

State, if in USA:

Location 11 Multiple Facility Information

Name of facility:

City:

State, if in USA:

Location 12 Multiple Facility Information

Name of facility:

City:

State, if in USA:

Location 13 Multiple Facility Information

Name of facility:

City:

State, if in USA:

Location 14 Multiple Facility Information

Name of facility:

City:

State:

15+ Multiple Facility Information

Please upload a spreadsheet or other document that lists all of your participating locations and includes their city and state.

Spreadsheet Multiple Facility Information

Please upload a spreadsheet or other document that lists all of your participating locations and includes their city and state.

Your DAISY Plan

Please enter the total number of DAISY Awards you expect to present each year. If you have questions about how many Awards you should present, please contact us:

When do you anticipate presenting your first Award? (We realize you do not have a specific date now, so please insert an approximate date for planning purposes only.)

About Your DAISY Coordinators

Who will be our main contacts?

DAISY Coordinator First Name:

DAISY Coordinator Last Name:

DAISY Coordinator Credentials:

DAISY Coordinator Title:

DAISY Coordinator Email:

DAISY Coordinator Phone (USA Format: (555) 555-5555. International Format: Please begin with + and Country Code):

DAISY Co-Coordinator: All DAISY programs should have at least two DAISY Coordinators. Please enter your second Coordinator's information below.

DAISY Co-Coordinator First Name:

DAISY Co-Coordinator Last Name:

DAISY Co-Coordinator Credentials:

DAISY Co-Coordinator Title:

DAISY Co-Coordinator Email:

DAISY Co-Coordinator Phone:

Name of the committee or team that will run The DAISY Award at your organization:

About Your Chief Nursing Officer

Please complete the following information as it should appear on your DAISY Award Certificate Template and to help us stay in touch with your CNO:

CNO First Name:

CNO Last Name:

CNO Credentials:

CNO Title:

CNO Email:

CNO Phone (USA Format: (555) 555-5555. International Format: Please begin with + and Country Code):

About Your Chief Executive Officer

So we may thank your Chief Executive Officer or Chief Operating Officer for her/his support for honoring your nurses, please tell us:

CEO First Name:

CEO Last Name:

CEO Credentials:

CEO Title:

CEO Email:

Additional Contacts:

Additional Contacts are not required, but are requested if you have someone in place at this time.

Administrative Support:
Please tell us if someone is providing administrative or clerical support to your DAISY Award, Program, such as an assistant or clerical person.

Administrative/Clerical Assistant's First Name:

Administrative/Clerical Assistant's Last Name:

Administrative/Clerical Assistant's Title:

Administrative/Clerical Assistant's Email:

Administrative/Clerical Assistant's Phone:

Marketing Support:

We recommend having someone from your marketing department work with your DAISY committee to raise awareness of your program among patients, families and staff. Please tell us if you would like us to contact one of your marketing representatives to assist in this process.

Marketing Contact First Name:

Marketing Contact Last Name:

Marketing Contact Email:

Marketing Contact Phone:

Shipping Information:
Once a year, we will ship your DAISY Award gifts for all facilities you have noted above. Please designate to whom we should ship by completing the information below in as much detail as possible.

Ship to Organization Name:

Ship to First Name:

Ship to Last Name:

Credentials, if applicable

Title:

Phone (USA Format: (555) 555-5555 International Format: Please begin with + and Country Code):

Country

Street Address:

Unit, mail-stop, room # - whatever it will take to ensure this package is delivered to you:

City:

State:

Provinces

State/Province

Postal Code

Additional Shipping Notes/ Information If Needed:

Funding Your DAISY Award Program

When you commit to The DAISY Award by completing this form, we will email an invoice to the person you designate below. This will pay for your first year's DAISY gifts and everything you need to get your program underway. We ask that you pay it within 60 days of commitment so that we have everything you need for your program when you need it. Thank you!

Are you part of the Veteran's Health Administration (VA)?

YesNo

What is the projected source of funding? (E.g. name of your hospital or organization, Corporate or Family Sponsor if you have one, Foundation funding the program, etc.):

Invoice to First Name:

Invoice to Last Name:

Email:

Phone:

Purchase Order (PO) number, if needed:

If the invoice should be addressed/ attention to to someone different than above, please enter the name (IE Accounts Payable, John Smith) please enter the name below:

If you have a third-party company who will be submitting payment, please enter the company name below:

Is the invoice contact listed above from your accounting department?:

Accounting Team Contact

Please provide us with a contact from your accounting team in case any questions/issues arise with your invoice or adding us to your system.

First Name:

Last Name:

Email:

Phone:

Finally...

How did you hear about The DAISY Award program?

Additional comments:

Full name of person who completed this form:

Email of person who completed this form:

By checking this box and submitting the online form, you agree to The DAISY Foundation collecting and storing your personal contact information. We may contact you if we have questions about your submission or to discuss next steps. To learn more, please read our Privacy Policy.

I Agree

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