Safety Star for Physician Offices & Healthcare Clinics Nomination Form

To nominate a physician office or healthcare clinic for the Safety Star Award, complete the form below.

Nominations must be received by October 13, 2023.

Steps to Submit a Complete Award Nomination:

  • Complete the nomination form and save a copy. A summary of your responses will be emailed to you after submission.
  • Ensure that each component of the nomination has been addressed.
  • Submit the nomination by Oct. 13, 2023.

A. General Information

1. Organization (must be a member of The Physicians Trust)


2. Physician or Practice Manager

3. Project Coordinator

Nomination Submitted By

B. Project Information

State the opportunity that was identified as a patient safety or quality of care concern, including targeted population. Please include information supporting improvement. Refer to “About Your Project” in the flyer for specific project examples.

Indicate the specific goal(s) which were set forth for this project.

Discuss the project plan. This section should include a discussion of the plan to achieve the goals and overall expected outcome of the project.

Discuss how the project was rolled out and who was involved. Discuss the project timeline of events. List barriers that were encountered and how they were overcome.

Summarize the results achieved. Please provide documentation to support positive results from this project.

Summarize how the project has improved patient safety or quality of care. Were any other positive impacts identified as a result of the project that were not foreseen?

Supporting Information

Please attach any supporting information that you have to support your improvement. The maximum allowed upload size is 64MB. Files must be uploaded as PDF or image format.