2012 NJ EMS Awards Nominations Survey

Thank you for taking the time to submit a nomination for the 2012 NJ EMS Awards! Please be sure to join us for the 2012 NJ EMS Awards Dinner, November 3, 2012 at the Sheraton Atlantic City; during the NJ Statewide Conference on EMS.

ALL NOMINATIONS MUST BE RECEIVED BY:
MONDAY, AUGUST 20, 2012 AT 5:00 pm

*

1. Please choose a award nomination category:

Please choose a award nomination category: Outstanding EMS Call

Outstanding EMS Action by a Youth

Outstanding EMS Action by a Citizen

Outstanding First Responder

Outstanding EMS Dispatcher

Outstanding Volunteer EMT-B

Outstanding Career EMT-B

Outstanding Paramedic

Outstanding ALS-SCTU Nurse

Outstanding EMS Physician

Outstanding EMS Administrator

Outstanding EMS Educator

Outstanding Volunteer EMS Agency

Outstanding Private EMS Agency

Outstanding Public EMS Agency

EMS Volunteer Lifetime Achievement Award

EMS Career Lifetime Achievement Award

Outstanding Hospital ER Nurse

Emergency Preparedness Achievement Award

*

2. LAST NAME or AGENCY NAME of whom you are nominating:

LAST NAME or AGENCY NAME of whom you are nominating:

3. FIRST NAME of person whom you are nominating

FIRST NAME of person whom you are nominating

*

4. Contact information of the person or agency that you are nominating:

Contact information of the person or agency that you are nominating: Address:
City/Town:
State:
ZIP:
Email Address:
Phone Number:

5. For "Outstanding EMS Call" Only: Additional Crew Member 2 (if applicable)

For "Outstanding EMS Call" Only: Additional Crew Member 2 (if applicable) Name:
Address:
City/Town:
State:
ZIP:
Email Address:
Phone Number:

6. For "Outstanding EMS Call" Only: Additional Crew Member 3 (if applicable)

For "Outstanding EMS Call" Only: Additional Crew Member 3 (if applicable) Name:
Address:
City/Town:
State:
ZIP:
Email Address:
Phone Number:

*

7. Please describe in detail (minimum of 300 words) why you feel this person or agency deserves to receive this award. Please be as descriptive as possible as this is the only information the awards committee will have to evaluate your nomination. (You may cut and paste your text into this box)

Please describe in detail (minimum of 300 words) why you feel this person or agency deserves to receive this award. Please be as descriptive as possible as this is the only information the awards committee will have to evaluate your nomination. (You may cut and paste your text into this box)

8. Please describe how this person or agency provides outstanding care; going above and beyond

Please describe how this person or agency provides outstanding care; going above and beyond

9. Please describe how this person or agency demonstrates outstanding character and is a role model for others

Please describe how this person or agency demonstrates outstanding character and is a role model for others

10. Please describe how this person or agency utilizes resources efficiently and effectively maximizing benefits

Please describe how this person or agency utilizes resources efficiently and effectively maximizing benefits

11. Please describe how this person or agency has advanced EMS through the use of new and innovative technologies, policies or procedures

Please describe how this person or agency has advanced EMS through the use of new and innovative technologies, policies or procedures

*

12. Your contact information. (This is needed in the event that the committee needs further clarification, or if they are unable to notify the person or agency that your are nominating.

Your contact information. (This is needed in the event that the committee needs further clarification, or if they are unable to notify the person or agency that your are nominating. Name:
Company:
Address:
City/Town:
State:
ZIP:
Email Address:
Phone Number:

2012 NJ EMS Awards Nominations
Exit this survey

2012 EMS Award Nomination Form

2012 NJ EMS Awards NominationsExit this survey

2012 EMS Award Nomination Form

2012 NJ EMS Awards Nominations
Exit this survey