Regional EMS Award for Outstanding EMS Agency Nomination Form

CRITERIA: An EMS agency that exemplifies outstanding professionalism and service to its community; whose high level of patient care is evident by innovative training, community awareness, preventative health programs, public relations efforts and participation in local, regional, state and national EMS systems.

ELIGIBILITY: Any 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. Includes governmental, commercial, volunteer, hospital, industrial and air ambulance services.

Select Award Category*

Award for Outstanding EMS Agency

Select Regional EMS Council*

Nominee Name*

Nominee Address*

Nominee Email*

Work Phone

Cell Phone*

Agency Affiliation*

Agency License 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 Agency being Nominated: Summarize and justify why this EMS agency should receive this award. You are encouraged to consider the following questions when providing your response to this section.*

a.) Why is this nominee exceptionally qualified and selected for this award? b.) How does this EMS agency support their providers? c.) Describe this EMS agency’s enhanced programs, which provide a high level of patient care that is evident through innovative training, community awareness, preventative health programs, public relations efforts and participation in the local, regional, state and national EMS systems.

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 Agency NOMINATION FORM