Regional EMS Award for Outstanding Contribution to EMS Health & Safety Nomination Form

CRITERIA: Any individual, program, business or licensed EMS agency within the Commonwealth of Virginia that has demonstrated comprehensive or significant accomplishments/programs that contribute or provide for the physical and or mental health, safety and well-being of EMS providers.

ELIGIBILITY: Any individual or official agency that is recognized by the state or federal government that is based in Virginia and is directly responsible for the health, safety and well-being of all people in Virginia.

Examples of programs meeting eligibility for this award would include EEMS provider health and wellness programs (fitness and wellness, cardiovascular health), scene safety programs (aeromedical operations, emergency vehicle operations), and provider injury prevention programs (injury prevention at violent scenes) designed to prevent line of duty death and injury.

Select Award Category*

Award for the Outstanding Contribution to EMS Health and Safety

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 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 individual or agency’s program or accomplishment deserve to be recognized? b.) Describe the accomplishment/program, including its objectives and target population being served and how it contributes to or provide for the physical and or mental health, safety and well-being of EMS providers. c.) Describe how the physical and or mental health, safety and well-being 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.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 Contribution to EMS Health and Safety NOMINATION FORM