2010 AEMS Aces of Hearts (AAH) Award Nomination Form
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1. 2010 AEMS Aces of Hearts Awards Nomination Form

January 2010

To All Central Arizona EMS and Trauma Colleagues:

Happy New Year! AEMS is pleased to annually coordinate and sponsor a recognition program that honors EMS and Trauma professionals and volunteers serving Central Arizona. This year marks AEMS ninth year in recognizing those who have provided outstanding contributions that enhance and improve emergency medical care.

We are committed to enhancing and expanding the participation and ownership of this process as well as fostering more inclusive recognition. For this reason, we are returning to an OPEN nomination process - where any healthcare professional may nominate a colleague who is an EMS/Trauma professional serving the Central Arizona Region.

The NEW process will works as follows. All nominations will be submitted to and collected by AEMS. AEMS will then organize all the nomination forms by agency/hospital. AEMS will identify and work with a primary contact person at the agency/hospital who will be responsible for selecting one final candidate from the *nominations received (*of individuals who work at their agency/hospital). While only the final recipients will actually receive the Aces of Hearts Award, ALL nominees will be acknowledged.

All Arizona healthcare professionals (aka the nominators) are encouraged and eligible to submit one nomination form with one nominee. The nominee must provide EMS or Trauma service in the Central Arizona region and may be either paid professionals or volunteers. The recipients of the Aces of Heart Award will receive a special recognition honor during the 10th Annual EMS Odyssey Conference held June 3-4, 2010. All nominees will receive a special acknowledgement for their service.

To nominate a colleague, thoroughly complete this application by February 28.

Note: the words described in your statement may be used as part of the awards ceremony.

Thank you for your anticipated cooperation and assistance with helping AEMS identifying the 2010 Aces of Hearts.

If you should have any questions, please contact:

Peggy Baker
Executive Director
AEMS
623-847-4100
pbaker@aems.org

INSTRUCTIONS:

You must complete all questions marked with astericks (*) in order to advance to the next page.

Please click "done" on the final page when you are finished completing the nomination form.

NOMINATOR INFORMATION (aka person making the nomination)

*
1. Nominator Name & Title:

Nominator Name & Title:

*
2. Agency / Hospital Name:

Agency / Hospital Name:

*
3. Address:
(Street/PO Box, City, State, & Zip):

Address: (Street/PO Box, City, State, & Zip):

*
4. Day Phone
(include area code):

Day Phone (include area code):

*
5. Email:

Email:

NOMINEE INFORMATION (aka person being nominated)

*
6. Nominee Name:

Nominee Name:

*
7. Title:

Title:

8. Address:
(if different from Nominators)

Address: (if different from Nominators)

*
9. Phone:
(include area code)

Phone: (include area code)

*
10. Email:

Email:

*
11. In 100 words or less, prepare a statement describing the nominee's qualities and contributions to EMS in Central Arizona. Include why the nominee should be recognized for her/his service:

In 100 words or less, prepare a statement describing the nominee's qualities and contributions to EMS in Central Arizona. Include why the nominee should be recognized for her/his service:

*
12. Provide at least two examples of the nominee's good work (please limit description of examples to one paragraph per example):

Provide at least two examples of the nominee's good work (please limit description of examples to one paragraph per example):

13. Provide a lighthearted / humorous / positive quip/story about the nominee (please limit to one paragraph):

Provide a lighthearted / humorous / positive quip/story about the nominee (please limit to one paragraph):

Please provide a photo of your nominee. Email your pic saved in jpeg format to: info@aems.org

2010 AEMS Aces of Hearts (AAH) Award Nomination FormExit this survey >>

1. 2010 AEMS Aces of Hearts Awards Nomination Form

*1. Nominator Name & Title:

*2. Agency / Hospital Name:

*3. Address:(Street/PO Box, City, State, & Zip):

*4. Day Phone (include area code):

*5. Email:

*6. Nominee Name:

*7. Title:

8. Address:(if different from Nominators)

*9. Phone:(include area code)

*10. Email:

*11. In 100 words or less, prepare a statement describing the nominee's qualities and contributions to EMS in Central Arizona. Include why the nominee should be recognized for her/his service:

*12. Provide at least two examples of the nominee's good work (please limit description of examples to one paragraph per example):