DSP Nomination Form

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DSP Nomination Form

Ashtabula County Board of Developmental Disabilities would like to recognize up to 3 DSPs each month that are providing exceptional services to individuals we support in Ashtabula County. This nomination can be submitted by individuals served, family members, County Board employees, and any provider agency or ICF in Ashtabula County.

We often hear about the exceptional work that DSPs are doing, and we wanted to provide an avenue for you all to share those DSPs stories with our community.

Please take a moment to complete this form.

Tell us:

Who you are.
Who you are nominating.
Where they work.
Why you think they deserve to be recognized as the DSP of the month.
Don't forget to give us specific examples of what they have done to make them an exceptional DSP.

We will present ALL nominations at our monthly Board meeting where up to 3 DSP's will be selected as that months DSP of the month. All award winners will be presented with a $25 award at our next Board meeting and will be highlighted on ACBDD's social media for that month.

At the end of the year ACBDD will hold an event honoring all DSPs that received awards throughout the year. At which time we will select a DSP of the YEAR! Help us celebrate your DSPs all year long!

If you have any questions about this program please contact Andrea Klimko, andrea.klimko@ashtabuladd.org.

Email *

Home Address of the DSP you are nominating. (this will be used for invitations to events and DSP signage drop offs.) *

How long has this person been a DSP? *

Name of DSP you are nominating *

Email Address of DSP you are nominating. *

Phone Number of the DSP you are nominating. *

The DSP you are nominating is a? *

Independent Provider

Waiver Agency Staff Member

ICF Staff member

Adult Day Services Staff Member

If they work for an agency, ICF or Day service, what is the name of that AGENCY? (If Independent indicate Independent.) *

Name of Person making this nomination. *

Email address or phone number of person making this nomination. *

What is your relationship to the person you are nominating for this award? *

I am the Individual receiving services.

Parent/Guardian/Family Member

County Board Staff Member

Supervisor

I am a peer that works with this DSP

Other

Please tell us why you are nominating this person for DSP of the month. *

THANK YOU for your Nomination! We will reach out to you and the person nominated once a selection has been made. ACBDD appreciates you all and all your hard work each and every day!

A copy of your responses will be emailed to the address you provided.

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