Magic Moments Nomination Form

Magic Moments Nomination Form

Caregivers are the heart of home-based healthcare, going above and beyond to provide exceptional support and compassion to those in need. The “Magic Moments” program, sponsored by Caribou Rewards, is designed to celebrate the outstanding contributions of home-based healthcare workers who make a difference every day. This year-round initiative recognizes acts of kindness, innovation, and excellence that truly exemplify the spirit of caregiving. Through this program, we aim to honor these extraordinary individuals, inspire others in the field, and highlight the critical role caregivers play in improving lives and strengthening communities.
Nominator's Name*

Your First NameYour Last Name
Nominator's Email Address*
example@example.com
Phone Number*
We may contact you if we need more information about your nomination
I am (choose one)*

Co-workerManagerPatient/ConsumerFamily member of Patient/ConsumerOther
Name of person being nominated: *

First NameLast Name
Email of person being nominated:*
example@example.com Put N/A if unknown
Phone Number of person being nominated:*
Please enter a valid phone number. Put N/A if unknown
Which agency does the person being nominated work at?*
Role of the person being nominated*

Caregiver or Direct Care Worker (DCW)Certified Nursing Assistant (CNA)Home Health Aide (HHA)Hospice AideLicensed Practical Nurse (LPN/LVN)Occupational Therapist (OT)Physical Therapist (PT)Speech-Language Pathologist (SLP)Social WorkerRegistered Nurse (RN)Other
Please choose the Nomination Category the best aligns with your submission*

Caught in the act: Recognizing exceptional moments of care and dedication that go beyond expectationsExceptional patient care: Highlighting professionals who consistently deliver outstanding, personalized careInnovative solutions: Acknowledging those who develop creative approaches to enhance care delivery and patient outcomesQuality champion: Recognizing professionals who maintain excellent standards with 90%+ EVV compliance
Please tell us why this person deserves to be recognized. Be detailed. *
Please be mindful of HIPAA
I understand that by providing my email address, I agree to receive emails from the Pennsylvania Homecare Association (PHA) & Caribou. I understand that I may opt out of receiving such communications at any time.
Should be Empty: