Awards and Recognitions Form

Office of Emergency Health Systems - EMS Program

Awards and Recognitions

Years of Service Award

Presented to EMS providers who achieve one, five, ten, fifteen, twenty, twenty-five years or more; or present a "Special Community Service in EMS" award to EMS Departments with milestone years of service to their community.

Special Delivery Award

Presented to individuals who assisted in the delivery of a baby while in their care on scene or en route to the hospital.

Code Save Award

Presented to individuals who assisted a patient in cardiac arrest which had a positive outcome.

Line of Duty Injury Recognition

Presented to an EMS provider who sustained a significant injury in the line of duty.

Name of the person submitting nomination

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Contact number

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Contact email

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Date of presentation or need awards by

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M-D-Y

Would you like the Award Presented by the State EMS Office?

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Yes

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What type of Award or Recognition?

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Name of Recipient	Department	Years of Service

Name of Recipient	Department	Special Delivery Date	Gender

Name of Recipient	Department	Code Save Date

Name of Recipient	Department	Line of Duty Injury Date

General Comments:

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