EMS Week Individual Nomination Form... - Utah Department of Health
EMS Week Individual Nomination Form... - Utah Department of Health
EMS Week Individual Nomination Form... - Utah Department of Health
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EMERGENCY MEDICAL SERVICES WEEK<br />
2013<br />
<strong>Nomination</strong> Deadline: March 29, 2013<br />
National Emergency Medical Services (<strong>EMS</strong>) <strong>Week</strong> 2013 “<strong>EMS</strong>: One Mission One Team” will be<br />
celebrated May 19th through May 25th, 2013. The Bureau <strong>of</strong> Emergency Medical Services and<br />
Preparedness honors the extraordinary service <strong>of</strong> those who provide day-to-day lifesaving services. The<br />
annual <strong>EMS</strong> Awards Ceremony is an excellent opportunity to recognize our state’s extraordinary <strong>EMS</strong><br />
pr<strong>of</strong>essionals and express our support as an Emergency Medical Community.<br />
The <strong>Utah</strong> <strong>Department</strong> <strong>of</strong> <strong>Health</strong>, Bureau <strong>of</strong> Emergency Medical Services and Preparedness, will<br />
be hosting the Awards Ceremony on Wednesday, May 22, 2013 at 10:00 a.m., at the <strong>Utah</strong> State Capitol<br />
Rotunda, State Capital, Salt Lake City, <strong>Utah</strong>.<br />
A nomination committee <strong>of</strong> <strong>EMS</strong> peers will select the Award Recipients. All Applications must be<br />
filled out completely with attached justification for each nomination.<br />
1. Emergency Physician <strong>of</strong> the Year<br />
Currently a <strong>Utah</strong> licensed emergency physician.<br />
Currently working with an <strong>EMS</strong> provider, air<br />
ambulance, or hospital emergency department within<br />
the <strong>Utah</strong> <strong>EMS</strong> system.<br />
Significant commitment to the success and<br />
advancement <strong>of</strong> the emergency medical system<br />
statewide.<br />
Exceptional contribution to the emergency medical<br />
education programs and support <strong>of</strong> <strong>EMS</strong> personnel,<br />
colleagues, and patients.<br />
2. Emergency Nurse <strong>of</strong> the Year<br />
Currently a <strong>Utah</strong> licensed emergency nurse working in<br />
an emergency medical department.<br />
Continually demonstrates excellent patient care clinical<br />
skills with exemplary pr<strong>of</strong>essionalism.<br />
Significant commitment to the success and<br />
advancement <strong>of</strong> the emergency medical system<br />
statewide.<br />
Exceptional contribution to the emergency medical<br />
education programs and support <strong>of</strong> <strong>EMS</strong> personnel,<br />
associates, and patients.<br />
3. Paramedic <strong>of</strong> the Year<br />
Currently a <strong>Utah</strong> certified paramedic.<br />
Continually demonstrates excellent patient care clinical<br />
skills with exemplary pr<strong>of</strong>essionalism.<br />
Significant commitment to the success and<br />
advancement <strong>of</strong> the emergency medical system<br />
statewide.<br />
Exceptional contribution to the emergency medical<br />
education programs and support <strong>of</strong> <strong>EMS</strong> personnel,<br />
associates, and patients.<br />
4. Emergency Medical Technician <strong>of</strong> the Year<br />
Currently a <strong>Utah</strong> certified EMT.<br />
Continually demonstrates excellent patient care clinical<br />
skills with exemplary pr<strong>of</strong>essionalism.<br />
Significant commitment to the success and<br />
advancement <strong>of</strong> the emergency medical system<br />
statewide.<br />
Exceptional contribution to the emergency medical<br />
education programs and support <strong>of</strong> <strong>EMS</strong> personnel,<br />
associates, and patients.<br />
<strong>EMS</strong> Award Criteria<br />
5. Emergency Medical Dispatcher <strong>of</strong> the Year<br />
Currently a <strong>Utah</strong> certified EMD.<br />
Continually demonstrates excellent Emergency<br />
Medical Dispatcher skills with exemplary<br />
pr<strong>of</strong>essionalism.<br />
Significant commitment to the success and<br />
advancement <strong>of</strong> the emergency medical dispatch<br />
system statewide.<br />
Exceptional contribution to the emergency medical<br />
education programs and support <strong>of</strong> <strong>EMS</strong> personnel,<br />
associates, and patients.<br />
6. Emergency Medical Instructor <strong>of</strong> the Year<br />
Currently a <strong>Utah</strong> certified Emergency Medical<br />
Instructor.<br />
Demonstrates excellent expertise in patient care<br />
clinical skills with exemplary pr<strong>of</strong>essionalism.<br />
Has a strong commitment to the success and<br />
advancement <strong>of</strong> emergency medical students<br />
statewide.<br />
Significant contribution to the emergency medical<br />
education programs and support <strong>of</strong> <strong>EMS</strong> personnel,<br />
associates, and students.<br />
Has shown exhaustive dedication to the success <strong>of</strong><br />
each student’s educational knowledge and competent<br />
patient skill level.<br />
7. Distinguished Service Award (<strong>EMS</strong> & <strong>EMS</strong>C)<br />
Has demonstrated their dedication to the <strong>EMS</strong><br />
pr<strong>of</strong>ession through longevity <strong>of</strong> service. (Suggested<br />
15 + years <strong>of</strong> service).<br />
Has made exceptional contribution in the scope <strong>of</strong><br />
<strong>Utah</strong> Emergency Medical Services.<br />
Has demonstrated their commitment in<br />
pr<strong>of</strong>essionalism and advancement in patient care<br />
through example, achievement, and promoting<br />
excellence within the <strong>EMS</strong> System.<br />
8. Citizen and/or Citizens <strong>of</strong> the Year<br />
Currently a <strong>Utah</strong> resident.<br />
An incident involving an exceptional emergency<br />
response by a private citizen and/or citizens which<br />
demonstrated quick thinking, good judgment, selfless<br />
courage, and a willingness to help another individual<br />
and as a result, positively impacted the patients<br />
outcome.
EMERGENCY MEDICAL SERVICES WEEK 2013<br />
Award <strong>Nomination</strong> Application<br />
<strong>Individual</strong> Outstanding Performance <strong>of</strong> the Year<br />
Deadline: March 29, 2013<br />
To Be Considered for an Award: PLEASE SUBMIT JUSTIFICATION ON ANOTHER PAGE AND<br />
PLEASE ATTACH JUSTIFICATION TO THIS NOMINATION FORM<br />
Nominator Contact Information (The Bureau might contact you if we need more information):<br />
Your Name: Email address:<br />
Phone Numbers:<br />
HOME: WORK: CELL:<br />
Address:<br />
Award Category: Please check an Award Category<br />
Outstanding Performance <strong>of</strong> the Year<br />
Emergency Physician Citizen <strong>of</strong> the Year<br />
Emergency Nurse<br />
Paramedic<br />
Emergency Medical Technician<br />
Emergency Medical Dispatcher<br />
<strong>EMS</strong> Instructor<br />
Distinguished Service Award<br />
Distinguished <strong>EMS</strong>C Coordinator Award<br />
<strong>Individual</strong> Nominee Contact Information:<br />
Name: Email address if possible<br />
Phone Numbers:<br />
HOME: WORK: CELL:<br />
Address:<br />
Agency: Phone:<br />
Address:
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