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


Criteria for this award:  An EMS physician who exemplifies outstanding leadership and dedication in the exercise of prehospital care.

Eligibility for this award:  Any licensed physician who is actively involved with prehospital care, training or mentorship of prehospital providers in the Commonwealth.  This can include emergency room physicians, operational medical directors, or other physicians who dedicate their time and knowledge to furthering education and patient care in EMS.

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:
Explain why this EMS physician exemplifies outstanding leadership and dedication in the exercise of prehospital care.*
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.*
Give specific examples (when applicable) of programs, new technologies or procedures that they have researched or implemented.*
Provide a description of the success and accomplishments of this person in EMS to include honors, awards (civic or professional) that highlights their contribution to EMS and their community.*
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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