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Pinckneyville Community Hospital

Employee Nomination Form

Please complete the form below.
  Employee Being Nominated:
  Person Nominating Employee:
Please select.
Employee     Patient     Visitor    
  Name of Nominator:
  Date:
  Reason for Nomination:
Nominations may be posted on the PCH website, Facebook, Making a Difference bulletin board or used in other marketing activities. The authro’s name will not be disclosed, and any information that is considered protected health information under HIPAA will be omitted. Please check here, if you prefer that we do NOT use your comments for marketing activities
  Yes     No