Your Contact Information

First Name *

Last Name *

Phone Number *

Email Address *

Are you a GBRH employee? *

Yes

Who are you nominating?

Employee First Name *

Employee Last Name *

Job Title *

Where do they work? *

Great Bend Regional Hospital

Central Kansas Family Practice

Heartland Regional Health Clinic

Please be as specific as possible in describing your experience with this employee. How did they go above and beyond their regular job duties to provide exceptional service? *

Today's Date (MM/DD/YYYY) *

Thank you for submitting a nomination! All entries received by the 20th of the month will be considered for that month's awards. Nominations received after the 20th will be considered for the next month's awards. Nominations are welcome at any time.

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Thank you for nominating a GBRH employee!