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Merck Patients First Award, 16750 Trans Canada Highway, Kirkland, Qc, H9H 4M7
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Merck Patients First Award for Excellence and Innovation in Patient-Centred Care
Instructions:

Please complete this form in consideration of the evaluation criteria, ensuring to use publicly-available information only. Pictures, PowerPoint slides, graphics or other attachments are not permitted in the text boxes.

All fields are mandatory.
Submissions are due by, December 6, 2019 (17h00 EDT).
Nominee (health professional, team, administrator or organization being nominated for an award)
 
Sharing of best practices is a key feature of the award.
Did the nominee expressly agree to this nomination?
“Nominees must be aware of and have expressly agreed to their nomination prior to submission.”
 
Name of the individual, team, administrator or health care organization being nominated
 
Geographical Location of the nominee (select only one option)
 
Contact information for nominee(s) (required so we can contact them if selected as an award recipient):
First Name
Last Name
Phone Number (000-000-0000)
Telephone Extension
E-mail Address
(Emails are used solely for the purposes of this award and will not be shared/used for any other purpose.)
 
Submission title. Provide a brief title for the submission story. (0/50)
 
Introduction. Provide background context for the nominee(s) and their patient-centred care work (e.g., 2-3 sentences). (0/500)
 
Innovation / Intervention. Describe how the nominee(s) are supporting / innovating in the field of patient-centred care (refer to the evaluation criteria to help craft your story). (0/2500)
 
Outcome / Impact. Describe how the nominee(s) are supporting / innovating in the field of patient-centred care (refer to the evaluation criteria to help craft your story). (0/2500)
 
Nominator: (person submitting the nomination form)
First Name
Last Name
E-mail Address
(Emails are used solely for the purposes of this award and will not be shared/used for any other purpose.)
 
Terms of Service By clicking ‘Submit’, I agree that the information provided is accurate to the best of my knowledge and I confirm that I have obtained the nominee’s adequate authorization. I also understand that the information provided will only be utilized for the purposes of the Merck Patients First Award initiative unless consent is otherwise provided. For more information about our Privacy Policy, click here.
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