Nominee Information

Name of Nominee*

Date*

Month/Day/Year

Job title*

Employer*

Direct Supervisor*

Street address

City

State/Region

ZIP / Postal Code

Phone number*

Email*

Nominator Information

Name of Person Nominating*

Primary Phone*

Contact Email*

Mailing Address*

Relationship to Navigator*

What are the dates of treatment or dates of your interaction with the nominee?*

Making it easier to get help: Help people find the resources they need.
Getting cancer services faster: Work to make sure people can get cancer services quickly and easily.
Offering support and guidance: Providing strong support and helping people get the care they need on time.
Making things clearer: Helping patients and their doctors communicate better and work together.
Helping understand diagnosis and treatments: Explaining cancer diagnoses and treatment options in a way that’s easy to understand, so patients and their loved ones feel informed.

How has the navigator demonstrated outstanding patient-centered care? (Please give specific examples.)*