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

CRITERIA: A nurse who exemplifies outstanding service in emergency medical services; knowledge and performance of EMS nursing skills; and high standards of cooperation and leadership with other EMS personnel and agencies. Highest consideration is given to performing a nursing role in a hospital or clinical setting such as precepting or quality assurance programs. Nurses who have demonstrated excellence as a prehospital provider or instructor should be nominated for those categories.

ELIGIBILITY: Any Virginia licensed nurse serving in an active role with local, regional, statewide and or national EMS.

Select Award Category*

Award for Nurse 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. How does this nurse exemplify outstanding service to EMS? b. Describe this nominee’s knowledge and performance, interaction and collaboration with EMS personnel and agencies. c. Does this nominee perform a nursing role in a hospital or clinical setting, such as precepting, educating or quality assurance programs? d. Does this nurse serve on any local, regional, statewide and or national EMS committees or groups? e. Additional recognition, awards and or commendations pertaining to EMS.

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 Nurse with Outstanding Contribution to EMS NOMINATION FORM