Interdisciplinary Commitment Declaration

(For Healthcare Organizations and Professional Organizations/Group Collaboratives)

The signatures below represent individu als who have played a substantial role in the initiative/project hereby being submitted for an ISMP CHEERS AWARD consideration. These individuals would be available to talk to ISMP staff or award committee members about their involvement in the projects or programs initiated should the award panel need clarification on points of interest.

Print Name/Signature _______________________________________________Date__________

Title___________________________________________________________________________

Phone ________________________________Email address: ____________________________

Print Name/Signature_______________________________________Date__________________

Title___________________________________________________________________________

Phone ________________________________Email address: ____________________________

Print Name/Signature_______________________________________Date_________________

Title_________________________________________________________________________

Phone ________________________________Email address: __________________________

Print this page, obtain signatures, and mail this page by the submission deadline to:

ISMP CHEERS AWARD Nomination
200 Lakeside Drive
Suite 200
Horsham, PA 19044

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