2018 Annual Conference Award Nominations

Question Title

* 1. Please indicate the award for which you are submitting a nomination:

Carl Kulczyk Memorial Award

Unsung Hero Award

Outstanding Provider Award

Question Title

* 2. Please complete the following information regarding your selected NOMINEE:

Nominee's Name

Nominee's Title

Nominee's Iowa PCA Member Organization

Nominee's E-Mail Address

Nominee's Telephone Number

Question Title

* 3. Please complete the following information regarding you the NOMINATOR:

Nominator's Name

Nominator's Title

Nominator's Iowa PCA Member Organization

Nominator's E-Mail Address

Nominator's Telephone Number

Question Title

* 4. Please complete the nomination statement:

A detailed description of why you think the nominee should receive the selected award. Responses should be typed into the following text area. The narrative should explain how the nominee meets the specific award criteria to merit recognition.

Include the following in the statement:
- Nominee’s years of service to the health center
- Examples of the nominee’s contributions to the health center and the community
- Other information supporting the nomination (optional)