LEADERSHIP DECLARATION

The following declaration should be read and signed by two executive leaders (e.g., Chief Executive Officer, Chief Operating Officer, Vice President Patient Care) that have oversight of the organization or the individual being nominated.

I acknowledge that the individual/group below is being nominated for an ISMP CHEERS AWARD. I have reviewed the submission material and validate the description presented as factual.

I understand that CHEERS AWARD winners are expected to share information regarding their winning submission with ISMP for external dissemination through publication and/or posting on the ISMP web page.

It is strongly encouraged that award winners (or designee from the organization) be present to accept their recognition at the ISMP CHEERS AWARD reception and dinner held during the American Society of Health-System Pharmacists (ASHP) midyear meeting, annually in December.

We certify that the information in this application is accurate.

#1 Print Name and Title__________________________________________________

Signature____________________________________________ Date__________

#2 Print Name and Title _____________________________________________________________

Signature _____________________________________________________Date__________

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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