Regional EMS Award for Outstanding EMS Prehospital Provider Nomination Form

CRITERIA: An individual who exemplifies outstanding dedication and service to his or her community through involvement with EMS. An individual that serves a mentor in growth and development of the EMS field.

ELIGIBILITY: Any individual who routinely provides prehospital care, primarily in Virginia, is affiliated with at least one Virginia licensed EMS agency and who is certified as a prehospital EMS provider by the Commonwealth of Virginia.

Select Award Category*

Award for Outstanding EMS Prehospital Provider

Select Regional EMS Council*

Nominee Name*

Nominee Address*

Nominee Email*

Work Phone

Cell Phone*

Agency Affiliation*

Nominee Certification Number

Position

Nomination Submitted By*

Address

Email*

Work Phone

Cell Phone*

DOCUMENTATION SUPPORTING NOMINATION

Read each statement below carefully and answer completely. Limit documentation to the information requested. Up to three documents may be attached to the nomination form. Of these items, one letter of support written by someone other than nominator must be included. Other documents may include a resume or CV, a newspaper article written about the nominee, etc.

Supporting Documentation

Drop files here or

Max. file size: 100 MB, Max. files: 3.

1. Brief Abstract of Person being Nominated: Summarize and justify why this person should receive this award. You are encouraged to consider the following questions when providing your response to this section.*

A.) Why is the nominee exceptionally qualified for this award? B.) Explain how this provider exemplifies outstanding dedication, mentorship of the field and investment to their community and delivery of prehospital care through involvement with EMS.

2. The Success & Accomplishments in EMS: Provide a description of the success and accomplishments of this person in EMS to include honors, awards (civic or professional) that highlights their contribution to EMS and their community in their local, regional, state and national EMS groups or committees?*

Photo Required: A photo of the nominee must be included. Try to send a color photo (with good lighting) with just the nominee in it. If it is an agency or organization, the photo can be a group shot of agency members, a picture of agency headquarters or a logo.*

Accepted file types: jpg, jpeg, png, gif.FileDescription

To verify the accuracy of the information provided in this nomination form, please type your First and Last Name, along with the date that you submitted this nomination form.

Name*

First Last

Date*

Regional EMS Award for Outstanding EMS Prehospital Provider NOMINATION FORM