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Award Nomination
Hospital Nursing Excellence Award Nomination & Patient Care Recognition Form
Volt theme
formbuilder.ai/f/hospital-nursing-excellence-award-nomination-patient-care-recognition-form
Hospital Nursing Excellence Award Nomination & Patient Care Recognition Form
Nominee's Name
· · ·
Nominee's Role
Unit / Department
Submit
3
Pages
19
Questions
~6min
To complete
Free
No credit card needed
Field types
Dropdown ×4
Full Name ×2
Single Choice ×2
Long Text ×2
Short Text
daterange
Multiple Choice
File Upload
Email
Phone
Yes / No
termsandconditions
Questions in this template
Free templateThe exact questions included — customize any of them to fit your needs.
Page 1
Nominee Information
5 questions
Nominee Information
1
Nominee's Name
*
Full Name
2
Nominee's Role
*
Dropdown
3
Unit / Department
*
Dropdown
4
Nurse's Shift (if known)
Single Choice
5
Room Number, Floor, or Other Identifying Details (helpful if you only know the nurse's first name)
Short Text
Page 2
Nomination Story
7 questions
Your Nomination Story
1
Award Category or Recognition Type
*
Dropdown
2
Date(s) of Care or Recognized Event
daterange
3
Describe the situation and what this nurse did that was extraordinary — please include specific examples
*
Long Text
4
How did this nurse's care make a difference for the patient, family, or care team?
Long Text
5
Which qualities did this nurse demonstrate? (Select all that apply)
*
Multiple Choice
6
Overall, how would you rate the care or support this nurse provided?
*
7
Supporting Letters, Thank-You Cards, or Photos
File Upload
Page 3
Your Information & Consent
7 questions
Your Information & Consent
1
Your Full Name
*
Full Name
2
Your Email Address
*
Email
3
Your Phone Number
Phone
4
Your Relationship to the Nominee
*
Dropdown
5
How may we share your nomination story?
*
Single Choice
6
May we contact you for more details or to invite you to the award presentation?
*
Yes / No
7
I confirm this nomination is truthful to the best of my knowledge and consent to the hospital using the information provided for recognition purposes, in line with my sharing preference and the hospital's privacy policy.
*
termsandconditions
How to use this template
Click "Use This Template Free" to open it in the FormBuilder editor. From there you can add, remove, or reorder fields with drag-and-drop, switch themes for instant restyling, add your logo, configure email notifications, and set your success message. When ready, publish with a unique link and start collecting responses immediately.
- Ready-to-use structure — pre-configured fields out of the box
- Applied "Volt" theme — fonts, colors, and layout already set
- Mobile-responsive — works on every device without extra configuration
- Fully editable with drag-and-drop — change anything in seconds
- Free to use on any plan, no credit card required
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