Form

Consent for storing submitted data *

Yes, I give permission to store and process my data No, I don't consent to storing and processing my data

Your full name *

Job title *

Your email address *

Name of the team or individual you are nominating *

Which Ward or department do they work in? *

Which value has the nominee demonstrated? *

Together Improving Safe Compassion

Nomminee's email address *

Where are they based? *

Royal Stoke County Hospital Other

Reason for this nomination *