REGIONAL EMS AWARDS

2008 NOMINATION FORM

PENINSULAS EMS COUNCIL

 

 

2008 Nomination Form

Regional Deadline: May 12, 2008
Regional Awards Picnic is June 7th at Beaver Dam Park, Gloucester

 

Check only one category on this nomination form. Make copies of the form to submit more than one nomination. Nominate only one person, agency, organization or call in a category. Failure to have nominee in most appropriate category may result in the nomination not being considered. Only one award is given in each category.

 

View the Printable Nomination Form for detailed instructions.
State Award Descriptions and Criteria

 

Not all fields are required at this time. Please fill out what you can and pay attention to the required fields.

 Required to select ONE

Award for Excellence in EMS

Award to the Outstanding Pre-Hospital Provider

Award to an Outstanding EMS Physician

Award to the Outstanding Pre-Hospital Educator

Award to the Nurse with Outstanding Contribution to EMS

Award to the Outstanding EMS Administrator

Award to the Outstanding EMS Agency

Award for the Outstanding Contribution to EMS

Award for Outstanding Contribution to EMS for Children

Award for Outstanding EMS Telecommunications Officer/Dispatcher

Award for Outstanding EMS Call (This is a Regional Award only)

 

NOMINEE’S NAME:  Required  (first)     (middle initial)        (last)         

 

ADDRESS:     Street        City         State         ZIP    

 

 PHONE:   Work                              Home                      

 

AGENCY AFFILIATION: Required        POSITION:  

 

NOMINATION SUBMITTED BY (Required for all nominee information) - NAME:       

 

ADDRESS:     Street         City           State         ZIP     

 

NOMINATOR’S PHONE:     Work or alternate       Home  

 

NOMINATOR’S SIGNATURE          Date     

 

DOCUMENTATION SUPPORTING NOMINATION

 

Read each statement carefully and answer completely. Limit documentation to information requested. A brief resume may be included. Up to four letters of support may be added to this form. If the nomination is not for an individual, but for an agency or organization, go directly to number 4.

 

  1. Required: List active, current and relevant offices or committee memberships at the local, regional and/or state levels. (Applies only to nominations of individuals.) 

     

 

  1. List current related certifications.

 

   3.    List honors and awards, civic or professional, received within the last 12 months. 

   4.  Required: Describe the nominee’s qualities and contributions (local, regional and state) to EMS in Virginia.

           Why is the nominee exceptionally qualified? Why should the nominee be selected for an award? This is              

           an important section and should be thoroughly addressed. A separate Word document may be sent.

         

        

         Separate Documents to be sent to jmeyer@vaems.org ?

               Yes

               No, everything is included here

 

Photo Required: A DIGITAL PHOTO (300dpi or high resolution 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, shot of agency headquarters or a logo. This can be sent to jmeyer@vaems.org

 

Important:  If you send a photo on a disk it must be a photo with 300 DPI or a high resolution photo.  If you aren’t certain send a glossy print instead. This will help assure the best image when used in publicity and printing. 

 

 

DO NOT DELAY NOMINATING AN INDIVIDUAL BECAUSE OF PHOTOGRAPH REQUIREMENTS.  CALL THE PEMS COUNCIL OFFICE AT (804) 693-6234 IF YOU REQUIRE ASSISTANCE WITH THIS REQUIREMENT.