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<p>Please fill out this form to nominate a deserving nurse for The DAISY Award.</p>\
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</div></div><p><strong>Tell Us About Yourself</strong></p><p>Thank you for taking the time to nominate an extraordinary, compassionate nurse for this award. Please tell us about yourself, so that we may include you in the celebration of this award if the nurse you nominated is selected.</p>\
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                        </fieldset><div class=\'form-group\'><label for=\'FormField6_5a204a7e-5657-4787-a8c5-6ba0e72168c7\' class=\'control-label  \'>I am (please select one)<span class=\'fb-required\'>*</span></label><div><select  name=\'FormField6_5a204a7e-5657-4787-a8c5-6ba0e72168c7\' id=\'FormField6_5a204a7e-5657-4787-a8c5-6ba0e72168c7\' class=\'form-control \' style=\'width: auto\' required data-msg-required=\'I am (please select one) is required.\' data-export-label=\'I_am__please_select_one\' ><option value=\'\' selected>( Please Select )</option><option value=\'Patient\'>Patient</option><option value=\'Family/Visitor\'>Family/Visitor</option><option value=\'Employee\'>Employee</option><option value=\'Physician\'>Physician</option><option value=\'Volunteer\'>Volunteer</option></select></div></div><div class=\'form-group\'><label for=\'FormField8_5a204a7e-5657-4787-a8c5-6ba0e72168c7\' class=\'control-label  \'>Phone Number</label><div><input type=\'text\' name=\'FormField8_5a204a7e-5657-4787-a8c5-6ba0e72168c7\' id=\'FormField8_5a204a7e-5657-4787-a8c5-6ba0e72168c7\' class=\'form-control input-medium \' value=\'\'  data-export-label=\'Phone_Number\'  data-rule-phoneUS=\'true\' data-msg-phoneUS=\'Please specify a valid phone number.\' />\
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</div></div><p>By indicating your name and that you are a patient of PIH Health Whittier Hospital, we are able to use your name and any information you provide as part of the nomination, for the purpose of announcing this particular award. If you are nominating someone, please do not include patient health information if the information does not pertain to yourself.</p>\
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