2019 Northern Virginia EMS Council Award Nomination For

Outstanding Contribution

to EMS Health & Safety

This is an offical nomination form for a regional EMS award. Please consider all the following information before you complete the form.

o        Has the nominee met all of the criteria for this award category? If not, please consider another category. Nominees that are incorrectly categorized will not be considered.

o        Do you have supporting materials if the category requires them? Supporting materials should be emailed to northern@vaems.org after you submit this form

o        You will need a high resolution digital photo of the nominee. Photo must be emailed to northern@vaems.org after you complete this form 

o        Will you meet the required deadline for entries?

o        Supporting materials and Photos can be sent after this form is completed.


Please fill out the following information below.

CRITERIA: 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: 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.

Nominee's Information


Your Information

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