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Westmoreland County
First Responder Recognition
Purpose:
This form is used to recognize and nominate first responders who have gone above and beyond in supporting individuals experiencing mental health challenges and/or drug and alcohol–related issues.
SECTION 1: NOMINATOR INFORMATION
1.
Nominator Name
2.
Nominator Email
3.
Nominator Phone Number
4.
Nominator Role/Organization
5.
Relationship to Individual
SECTION 2: FIRST RESPONDER BEING NOMINATED
6.
Name of First Responder
7.
Agency/Department
8.
Type of Agency:
Police
EMS
Fire
Dispatch
Coroner
9.
Position/Title
10.
Years of Service
SECTION 3: INCIDENT INFORMATION
11.
Date of Incident
12.
Location
13.
Type of Incident
Mental Health Crisis
Substance use/overdose
Co-occurring mental health and substance use
Suicide Prevention and Post Engagement
SECTION 4
14.
Describe how the First Responder helped the individual(s)
(You may want to type this information into Microsoft Word or Notes and paste it into this section)
SECTION 5
15.
Impact (Describe the impact of the responder's actions)
(You may want to type this information into Microsoft Word or Notes and paste it into this section)
For any questions, email Julie at jlovis@wedacinc.org
