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* 1. First and last name

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* 2. Badge #

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* 3. Facility name and department

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* 4. Email

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* 5. Phone Number 

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* 6. Current role

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* 7. What is your ethnicity?

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* 8. Tell us a little about your background. Where are you from? How long have you worked here? How long have you been in your role?

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* 9. When did you begin working at Kettering Health Network?

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* 10. What is your greatest accomplishment at Kettering Health Network? 

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* 11. What drew you to work here at Kettering Health Network?

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* 12. What inspires you in your job?

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* 13. What challenges have you/your family had to overcome to get where you are?

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* 14. What is your favorite childhood memory? (i.e. food, music, etc.)

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* 15. What advice would you give people in regard to their careers? 

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* 16. Please submit a photo of yourself to be used for the story

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* 17. By checking this box, I am giving Kettering Health Network permission to use the information I have provided.

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