I. Nominee Information:

Nominee:

Title:

Facility/Agency Name:

Facility Address:

City, State, and Zip:

Nominee works in the following community/facility setting (Please select only one):

Community Based Care
In-Home Care Agency
Nursing Facility
Senior Retirement

Length of Commitment:

Months   Years

II. Nominator Contact Information:

Nomination Submitted By:

Title:

Facility:

Phone:

Email:

III. Please list 3-5 reasons why this Nominee deserves to be recognized as an OHCA Champion-of-the-Month:
(Bullet points are limited to 150 words each, maximum of 750 words per nomination).

1.

2.

3.

4.

5.

Photo of Nominee: Please email your image to mking@ohca.com

By submitting a nomination form & picture of the nominee both nominee & nominator agree to allow OHCA to publish and use the pictures and narrative from nomination on the OHCA website, OHCA newsletter and any marketing materials OHCA deems fit. OHCA promises to use all information in a tasteful manner. If you have question about the use of the pictures, please email your question to mking@ohca.com.