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Works of Heart Submission Form
2019-10-03T15:07:56-05:00
WORKS OF HEART – Official Submission Form
Your Information
First Name
*
Last Name
*
Email
*
Enter Email
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Phone
*
Location
*
City
State / Province / Region
I am a – select from below
*
-
Community Member (non-patient)
Healthcare Worker
Patient
My nomination for Works of Heart
Tell us who you’re nominating (include first and last name) and what makes this person unique.
*
Tell us who you’re nominating (include first and last name) and what makes this person unique.
*
Tell us where they work and how they’re impacting patients, healthcare community and/or organization.
*
Tell us where they work and how they’re impacting patients, healthcare community and/or organization.
*
Tell us how this healthcare worker went above and beyond daily duties to improve healthcare.
*
Tell us how this healthcare worker went above and beyond daily duties to improve healthcare.
*
Tell us how this healthcare worker uses patient empathy to improve healthcare?
*
Tell us how this healthcare worker uses patient empathy to improve healthcare?
*
Image of the person you are nominating (jpeg, png, gif, and tiff files accepted)
Do you have a photo to submit? Optional.
No
Yes
Photo Upload
Accepted file types: jpg, jpeg, png, gif, tiff.
2MB max
Link to video about the person you are nominating (YouTube, Vimeo, or any other URL based video link accepted)
Do you have a video submission? Optional.
No
Yes
Video Link
Please provide the URL to the video.
How did you hear about the program?
Please select below. Optional.
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Media Story
Social Media Post
Conference
Friend/Family/Coworker
Terms and Conditions
*
I acknowledge that this contest is subject to the
Official Rules
. By submitting an entry, I am agreeing to those Official Rules. This is not a sweepstakes; no purchase necessary. Medline employees and their immediate family (spouses, parents, children and siblings) are not eligible to enter or be nominated.
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