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South Central Kansas Regional Medical Center

Exceptional Service Award Nomination Form

Use this form to recognize staff for going above and beyond!
Simply complete the section below. We appreciate your feedback in rewarding those individuals who provide outstanding customer service, exceptional dedication to the team,or high quality patient care.
* Nominee
The person you are recognizing.
  Department
* Date of Service
* How did this person provide you with exceptional service?
  Submitted by
* May we use your name and comments in promoting the medical centerís services through the use of newspaper, radio, online, and/or other forms of advertising? Yes
No
* Which of the following best describes your reason for being at SCKMC