Stroke Champion Nomination Form

Stroke Champion Nomination

Nominee Name * Required
First Last
Submitted By * Required
First Last
Hospital * Required
Nominee has scored a 90% or above on the nurse performance consult score sheet: * Required
- Yes
- No
The Door to Needle time target of the nominees call was: * Required
- 46-60 minutes
- 31-45 minutes
- 30 minutes or less
Nominee qualifies for the BRONZE CLUB
Nominee qualifies for the SILVER CLUB
Nominee qualifies for GOLD CLUB