PEMS Regional EMS Award for Nurse with Outstanding Contribution to EMS Nomination Form


Criteria for this award:A nurse who exemplifies outstanding service in emergency medical services; knowledge and performance of EMS nursing skills; and high standards of cooperation and leadership with other EMS personnel and agencies. Highest consideration is given to performing a nursing role in a hospital or clinical setting such as precepting or quality assurance programs. Nurses who have demonstrated excellence as a prehospital provider or instructor should be nominated for those categories.

Eligibility for this award:Any Virginia licensed nurse serving in an active position.

Name of Nominee:*
Nominee Agency or Organization:*
Nominee Phone:*
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Nominee E-mail:*
Address of Nominee:*
Submitter Information
Submitted by:*
Submitter E-mail:*
Submitter Phone:*
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Brief Abstract of Nominee:
Why does this nurse exemplify outstanding service in emergency medical services?*
Describe this nominee’s knowledge and performance of EMS nursing skills.*
How does this nominee practice high standards of cooperation and leadership with other EMS personnel and agencies?*
Describe the nominee’s contributions (local, regional and state) to EMS and emergency nursing in Virginia*
Does this nominee perform a nursing role in a hospital or clinical setting, such as precepting or quality assurance programs? *
Does this nominee demonstrate excellence as a prehospital provider or instructor? If so, then would this nominee be better suited for one of those categories?*
Does this nurse sit on any local, regional or state committees?*
Supporting Documents:
Upload High Resolution Photographs of Nominee:
Letters of Recommendation:
Resume/CV:
Other supporting documents (newspaper/periodical articles, press releases, etc.)
Ready to submit?

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