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Z EMS Week 2020 ~ Nominations for EMS Team / Provider Recognition
EMS Week 2020 ~ Nominations for EMS Team / Provider Recognition
We are looking for your help to recognize outstanding NYS EMS Providers during EMS Week 2020!
Thank You! That is what the New York State Bureau of Emergency Medical Services would like to say to all our EMS Providers during EMS Week 2020.
With the understanding this year’s EMS Week will be a little different then years past, the Bureau would like to take some time to recognize some of those EMS teams/providers who have gone above and beyond this year to help others.
The Bureau is doing something new this year and offering EMS agencies the opportunity to directly nominate a team or provider to be recognized during EMS Week for their contributions to Emergency Medical Services.
Below is a submission form where EMS agencies can make a nomination.
https://apps.health.ny.gov/pubpal/builder/survey/ems-week-2020-ems-team-and-emt-r
NOMINATION GUIDELINES:
ONE NOMINATION
: One nomination is permitted per agency; however, the nomination can be an individual or a team (team being a department company, specific group, the agency, etc.)
GOOD STANDING
: Nominated individuals or team members must be in good standing with the Department of Health
SUBMISSION BY
: Submissions will be accepted from an EMS agency, Course Sponsor, County EMS Coordinator, REMSCO, REMAC or Program Agency (only one nomination is permitted from each organization)
NOMINATION INFORMATION
(the info needed to complete the form):
AGENCY CONTACT INFO
: Contact information for the agency and the agency leader
NOMINEE CONTACT INFO
: the form does ask for contact information of the nominee or the primary point of contact for a team. Please make sure you have an e-mail address.
CATAGORIES
: We have selected the following categories:
Clinical Performance
Agency / Regional Leadership
Training and Education
Operations
Innovation and Teamwork
Other: If your agency feels there is a different reason, we gave you an “other” option to create a different category!
THREE HIGHLIGHTS
: Think about three reasons (a few words or one sentence each) on why you feel they should be nominated.
Submission for nominations are OPEN NOW!
The nominations will remain open until we have met our maxiumn number, so we encourage agencies to submit early, but remember, you can only submit once.
Thank you to every NYS EMS Provider, we really appreaite all the work your are doing every day and especially during these very challanging times.
Happy EMS Week!
Ryan Greenberg
Director
Bureau of EMS & Trauma Systems
EMS Agency Information
EMS Agency Name
Enter the name as it appears on the agency's Certificate of Need.
EMS Agency Code
Enter the four digit code as it appears on the EMS Agency's Certificate of Need. If an agency code is not available or doesn't apply to the individual submitting the nomination, this field may be blank.
EMS Agency Leadership Contact
The individual submitting the nomination does not need to be the leader of the EMS Agency or organization.
First Name
Last Name
Agency Leadership Title
Agency Leadership Title
- Select -
Captain / Chief
Executive Director
Director of Operations
Training Officer
Field Supervisor
Mentor / Field Training Officer
County Coordinator
Deputy County Coordinator
Other…
Enter other…
Direct Contact Number
Type
- Type -
Home
Office
Cell
Phone
EMS Agency Leadership Email
EMS Agency Leadership Email
Confirm email
Nomination Submitted By
The individual submitting the nomination may be the same as the agency or organization leadership.
Submitter First Name
Submitter Last Name
Submitter Leadership Title
Submitter Leadership Title
- Select -
Captain / Chief
Executive Director
Director of Operations
Training Officer
Field Supervisor
Mentor / Field Training Officer
County Coordinator
Deputy County Coordinator
Other…
Enter other…
Submitter Direct Contact Number
Type
- Type -
Home
Office
Cell
Phone
Submitter Email Address
Submitter Email Address
Confirm email
Nomination (Individual or Team)
Please submit all information on the individual or team performing outstanding work.
Type of Nomination
Individual
Team
Individual Nomination
Nominee Last Name
Nominee First Name
EMT #
Please enter the six digit EMT number, if the nominee is an EMT (at any level of care).
Individual Nominee Phone #
Type
- Type -
Home
Office
Cell
Phone
Individual Nominee Email Address
Individual Nominee Email Address
Confirm email
A valid personal email address is important as communication may be sent to a selected recipient via email.
Nominee Home Mailing Address
Address
Address 2
City/Town
State
- Select -
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces (Canada, Europe, Africa, or Middle East)
Armed Forces Americas
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federate States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP/Postal Code
If home address is not know, please enter EMS Agency or Organization Address.
Nomination Category
Clinical
Leadership
Training / Education
Operations
Innovation
Team Work
Other…
Enter other…
Please select a category for the nomination. There should be only
one
nomination in total from each EMS Agency.
To complete the nomination, please submit three (3) reasons supporting the nomination.
Individual Nominee Reason #1
Individual Nominee Reason #2
Individual Nominee Reason #3
Additional Information
Please add any additional comments that support the nomination.
Team Nomination
Team Name
Team Leader First Name
Team Leader Last Name
Team Leader Direct Phone #
Type
- Type -
Home
Office
Cell
Phone
Team Leader Direct Email
Team Leader Direct Email
Confirm email
Nominated Team / Company Members
Please list press <enter> after each line and before entering each additional person on the team.
Team Nomination Category
Clinical
Leadership
Training / Education
Operations
Innovation
Team Work
Other…
Enter other…
Please select a category for the nomination. There should be only
one
nomination in total from each EMS Agency.
Team Nomination Reason #1
Team Nomination Reason #2
Team Nomination Reason #3
Team Nomination
Please provide any information you believe will support the nomination in addition to the three reasons sited above.
Submit