PEMS Regional EMS Award for Outstanding Contribution to EMS Health & Safety Nomination Form


Criteria for this award:  Any individual, program, business or licensed EMS Agency within the Commonwealth of Virginia that has demonstrated comprehensive and/or significant accomplishments/programs that make a significant contribution to or provide for the health, safety and welfare of EMS providers.

Eligibility for this award:  Any individual, program, business or licensed EMS Agency within the Commonwealth of Virginia.


Examples of programs meeting eligibility for this award would include EMS provider health and wellness programs (fitness and wellness, cardiovascular health), scene safety programs (aeromedical operations, emergency vehicle operations), and provider injury prevention programs (injury prevention at violent scenes) designed to prevent line of duty death and injury. Eligible applicants include persons or entities developing or managing such programs.

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 program/accomplishment deserve to be recognized?*
b. Describe the accomplishment/program, including its objectives and clientele being served and how it contributes to or provide for the health, safety and welfare of EMS providers.*
Provide a description of the results and success of the accomplishment/program.*
How were the objectives met? Provide examples and outcome measurements when possible.*
Give detailed results analysis of the program. *
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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