2010 Employee of the Year

Required information is marked by an asterisk (*)

This is a nomination for the following category
(Select only one category per form):

Facility Name: *

Address:

City, State Zip:

Phone:

Fax:

E-mail: *

Nomination Submitted By:
Name:

Title:

Accurate and Full Name of Nominee Name:

Address:
(This address will be used to mail Luncheon invitation):

City, State Zip:

Length of service in long-term care (in years):

Length of volunteer service at nominating facility (in years):

The following questions must be completed. Remember to type your answers and to use 250 words or less for each question. You may use a separate sheet of paper if necessary.

PLEASE DO NOT REFER TO THE EMPLOYEE’S NAME, FACILITY NAME OR FACILITY LOCATION.

What impact has the employee had on your facility?

State how nominee is an exemplary representative of the long-term care industry.

How have residents/family members acknowledged the value of the nominee’s contribution to them?

Message: