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

Regional EMS Award for Physician with Outstanding Contribution to EMS NOMINATION FORM

  • 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.
  • Drop files here or
  • A.) Explain why this EMS physician exemplifies outstanding leadership and dedication in the exercise of prehospital care. B.) How does this physician go above and beyond their duties to enhance EMS care, education and support of the EMS system in their region/community and the state? C.) Give specific examples (when applicable) of programs, new technologies or procedures that they have researched or implemented.
  • Date Format: MM slash DD slash YYYY