Regional EMS Award for Outstanding Contribution to EMS Emergency Preparedness and Response Nomination Form Regional EMS Award for Outstanding Contribution to EMS Emergency Preparedness and Response NOMINATION FORM CRITERIA: Any individual, EMS organization or EMS response group within the Commonwealth of Virginia that has demonstrated comprehensive and/or significant accomplishments for programs that provide preparedness, response and recovery from natural, man-made and preplanned events, which cause a significant impact on the agency and the community. ELIGIBILITY: Any individual currently licensed or official agency that is recognized by the state or federal government that is based in Virginia and is directly responsible for responding to emergencies or disasters and providing the direct delivery of care. Examples of programs meeting eligibility for this award would include; Disaster Response Teams, Community Emergency Response Teams, Continuity of Operations Planning, Mass Casualty Incident Training programs, all-hazards planning, emergency management partnerships and surge event planning.Select Award Category* Award for the Outstanding Contribution to EMS Emergency Preparedness and Response Select Regional EMS Council*Select Your Regional Council HereBlue Ridge EMS CouncilCentral Shenandoah EMS CouncilLord Fairfax EMS CouncilNorthern Virginia EMS CouncilOld Dominion EMS AlliancePeninsulas EMS CouncilRappahannock EMS CouncilSouthwest Virginia EMS CouncilThomas Jefferson EMS CouncilTidewater EMS CouncilWestern Virginia EMS CouncilNominee Name*Nominee Address*Nominee Email* Work PhoneCell Phone*Agency Affiliation*Nominee Certification NumberIf nominating an agency, please include the agency license number here. PositionNomination Submitted By*AddressEmail*Work PhoneCell 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 Select files Max. file size: 100 MB, Max. files: 3. 1. Brief Description of Individual or EMS Agency Nominated: Summarize and justify why this person or agency should receive this award. You are encouraged to consider the following questions when providing your response to this section.*a.) Why does this program/accomplishment deserve to be recognized? Examples include all-hazards planning, emergency management partnerships, work in emergency life cycle, etc. b.) Describe the demonstrated comprehensive and/or significant accomplishments/programs that contribute towards making their communities safer, stronger, better prepared and more resilient through emergency preparedness and response. c.) Describe how the mitigation, preparedness, response, recovery objectives were 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.FileDescriptionTo 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* MM slash DD slash YYYY Last Updated: February 6, 2019