Regional EMS Award for Nurse with Outstanding Contribution to EMS Nomination Form A nurse who exemplifies outstanding service in emergency medical services; knowledge and CRITERIA: performance of EMS nursing skills; and high standards of cooperation and leadership with other personnel and agencies. Highest consideration is given to performing a nursing role in a hospital or clinical setting such as precepting or quality assurance programs. Nurses who have demonstrated excellence as a prehospital provider or instructor should be nominated for those categories. Any licensed serving in an active position. ELIGIBILITY: ____ Award for Nurse with Outstanding Contribution to EMS Nominee Name: Address: Street: City: State: Zip: Email: Phone: Work: Cell: Agency/ Hospital Position: Affiliation: Nomination Submitted By: Address: Street: City: State: Zip: Email: Work: Cell: Phone: NOMINATOR’S SIGNATURE ____________________________ Date ________________
Regional EMS Award for Nurse with Outstanding Contribution to EMS Nomination Form CRITERIA: A nurse who exemplifies outstanding service in emergency medical services; knowledge and performance of EMS nursing skills; and high standards of cooperation and leadership with other personnel and agencies. Highest consideration is given to performing a nursing role in a hospital or clinical setting such as precepting or quality assurance programs. Nurses who have demonstrated excellence as a prehospital provider or instructor should be nominated for those categories. ELIGIBILITY: Any licensed serving in an active position. ____ Award for Nurse with Outstanding Contribution to EMS Nominee Name: Address: Street: City: State: Zip: Email: Phone: Work: Cell: Agency/ Hospital Affiliation: Position: Nomination Submitted By: Address: Street: City: State: Zip: Email: Phone: Work: Cell: NOMINATOR’S SIGNATURE ____________________________ Date ________________
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