Health Care Worker of the Year Nomination Form

Wisconsin's First Congressional District’s Health Care Worker of the Year Award will recognize an unsung hero in Wisconsin's First Congressional District who has gone above and beyond to help our community and their patients.

The recipient of the Health Care Worker of the Year Award will be selected based on the following criteria:

Displays exemplary service and performance in their profession
Upholds the standard of providing unsurpassed care and treatment for their patients
Goes above and beyond the call of duty in performing their responsibilities
Displays self-sacrifice and selflessness in caring for others

The nominee must reside in Wisconsin's First Congressional District (nominee may work at a facility outside the First District) and be a licensed health care professional (doctor, nurse, nurse practitioner, physician assistant, etc.)

If you have questions, please contact our office at 608-752-4050.

Nominations Due by July 1st, 2022

Indicates required field

Nominee Information:

Nominee's Name:

Profession:

Address

City/Town

State/Province

ZIP/Postal Code

Phone

Work Phone (If Known)

Work Email (If Known)

Submitted By:

Name:

Phone

Describe Your Nominee:

Please write a minimum of 4-5 sentences on how the nominee meets the above criteria. You may provide examples.