2019 Northern Virginia EMS Council Award Nomination For

Pre-Hospital Physician Award

 

 

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: An EMS physician who exemplifies outstanding leadership and dedication in the exercise of pre-hospital care.

 

ELIGIBILITY: Any licensed physician who is actively involved with pre-hospital care, training or mentorship of pre-hospital providers in the Commonwealth. This can include emergency room physicians, operational medical directors, or other physicians who dedicate their time and knowledge to furthering education and patient care in EMS. 

Nominee's Information

----------------------------------------------------------------------------------------------------------------------------------

Your Information

Powered by ChronoForms - ChronoEngine.com

Back To Top Website Security Test