Hattiesburg Clinic Employee Recognition Form

At Hattiesburg Clinic, it is our mission to provide quality care and excellent service to all who visit our facilities. Through our Employee Recognition Program, we recognize individuals who give of themselves above and beyond what is commonly expected.

If you received exceptional service from a member of our staff, please take a moment and complete the following recognition form. Your comments will be shared with our employee who will receive a special thank you on your behalf. The individual you recognize may also be eligible as a nominee for our Employee of the Quarter Award.

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* 1. Hattiesburg Clinic employee you wish to recognize:

First Name

Last Name

Department

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* 2. How did our employee provide exceptional service? (Please be specific and provide as much detail as possible.)

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* 3. Your Information:

First Name

Last Name

Phone number

Date of your visit (mm/dd/year)

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* 4. May we disclose your name to the recipient?

Yes

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* 5. May we use your name and story as part of our internal or external publicity (such as employee newsletters, bulletin boards, etc.)?

Yes

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* 6. Please indicate your category:

Patient

Family member of patient

Business visitor

Other