Regional EMS Award for Outstanding Contribution to EMS Telecommunication

CRITERIA: An emergency medical telecommunicator, public safety answering point administrator, supervisor or training officer whose outstanding dedication and service has demonstrated an exceptional contribution to the improved delivery of emergency medical services in the local, regional, statewide and or national EMS system.

ELIGIBILITY: An emergency medical telecommunicator, public safety answering point administrator, supervisor or training officer who is employed or volunteers with an emergency medical services dispatch center or public safety answering point in Virginia.

Select Award Category*

Award for Outstanding Contribution to EMS Telecommunication

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 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 person’s dedication and service has demonstrated an exceptional contribution; improved delivery of emergency medical services in the local, regional, state and national EMS system. b.) Are there any programs or events that they have implemented or educational programs that they have created or enhanced? c.) Does this nominee provide any other volunteer or career services within the EMS system at the local, regional, state and national level?

2. A leader and advocate for EMS Telecommunications: Describe how this nominee has been recognized for extraordinary EMD services or honors. You are encouraged to consider the following questions when providing your response to this section.*

a. Does this nominee serve on any committees or participate with any groups that help to enhance and advocate for EMS and/or telecommunications at the local, regional, state and national level?

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 EMS Telecommunicator NOMINATION FORM