Regional EMS Award for Physician with Outstanding Contribution to EMS Nomination Form

CRITERIA: A Virginia licensed physician who exemplifies outstanding leadership and dedication in prehospital care.

ELIGIBILITY: A Virginia licensed physician who is involved with prehospital care, training or mentorship of prehospital providers in the Commonwealth. This can include emergency room physicians, operational medical directors, or other physicians who dedicate their time and knowledge to furthering education and patient care in EMS.

Select Award Category*

Award for Physician with Outstanding Contribution to EMS

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.

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.) Describe how this EMS physician exemplifies outstanding leadership and dedication in the delivery of prehospital care. b.) How does this physician go above and beyond their duties to enhance EMS care, education and support of the EMS system in their local, regional, statewide or national EMS groups or committees? c.) Give specific examples (when applicable) of programs, new technologies or procedures that they have researched or implemented. d.) 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.

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 Physician with Outstanding Contribution to EMS NOMINATION FORM