Regional EMS Award for Innovation Excellence in EMS

CRITERIA: An EMS provider, EMS agency or private/public organization that exemplifies innovative excellence and advancement at the local, regional, statewide and national level. Must have demonstrated a commitment to an innovative, comprehensive and unified system of Emergency Medical Services throughout the Commonwealth.

ELIGIBILITY: Any individual, EMS agency, program, organization, public or private entity involved in Emergency Medical Services.

Select Award Category*

Award for Innovation in EMS

Select Regional EMS Council*

Nominee Name*

Nominee Address*

Nominee Email*

Work Phone

Cell Phone*

Agency Affiliation*

Nominee Certification Number

If nominating an agency, please include the agency license number here.

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 or Agency being Nominated: Summarize and justify why this person/organization should receive this award. You are encouraged to consider the following questions when providing your response to this section.*

a. How has this individual /organization made a difference in Virginia’s EMS System through innovative contributions and initiatives? Has this innovative initiative been utilized to address a problem that affects the EMS community; identified challenges or gaps in patient care; or enhanced patient satisfaction? b. What areas of the EMS system have been influenced by the work of the individual or organization? c. What changes or outcome examples have occurred following the implementation of the new or enhanced program/product developed by the nominee? How were the objectives met? Provide examples and outcome measurements when possible.

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.

Nominator's Name*

First Last

Date of Document Submission:*

Regional EMS Award for Innovation in EMS NOMINATION FORM