Regional EMS Award for Outstanding EMS Leadership Nomination Form

CRITERIA: An individual who has demonstrated ability to organize, conduct, manage, problem solve and evaluate within their organization and, by exemplary leadership and administrative skills, improve the effectiveness, response and delivery of EMS.

ELIGIBILITY: Any person responsible for chairing, presiding over, supervising or administering EMS organizations and/or personnel in Virginia.

Select Award Category*

Award for Outstanding EMS Leadership

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 has this individual demonstrated an ability to organize, conduct, manage, problem solve, evaluate, etc within their organization? b.) Does this leader participate on any committees or participate with programs that help to further enhance EMS and patient care within their locality, region, state or nation? c.) How has this individual, through exemplary leadership and administrative skills, improved the effectiveness, response and delivery of EMS? d.) 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 Outstanding EMS Leadership NOMINATION FORM