Moments of Magic: Nomination Form

Reference

Tell us what happened.*

This will be published on our intranet and public website, so please do not include anything that could be used to identify a patient.

Which members of staff or teams were involved?*

This information will be published on our intranet and public website.

Where do they work?*

This information will be published on our intranet and public website.

If known, tell us their job role(s).

This information will be published on our intranet and public website.

At the time, I was a...*

This information will be published on our intranet and public website.

If you have any supporting documentation, or a video you'd like to add, please upload here.

Drop files here or

Max. file size: 500 MB.

Maximum file size: 500MB

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Would you like to answer some additional questions, which will allow the Trust to learn from excellent events?*

No - I would prefer to submit this as a thank you only
Yes - I would like to answer some further questions to help the Trust to learn from this excellent event

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What do you think we could learn from this?*

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If known, tell us the date this happened.

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If known, tell us the time this happened.

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Would you like to tell us who you are?*

We will never publish your name or contact details online. They will only be used if we need to contact you regarding your submission, e.g. if it wins a special award, or if we need further details.

Yes - I would like to tell you who I am and give you my contact details
No - I would prefer to remain anonymous and understand this means I will not be contactable if my submission wins an award

Your Contact Details

What is your name?*

What is your email address?*

What is your phone number?

What is your job title?

If you are a member of staff.

Which department do you work in?

If you are a member of staff.

What happens after I submit this form?

Please review the Terms and Conditions (opens in a new window, which you can safely close after reading) and ensure you understand them before submitting your nomination.

Terms and Conditions*

I confirm I have read and understood the Terms and Conditions

Phone

This field is for validation purposes and should be left unchanged.