Excellence in EMS Nomination Name(Required) First Last I am: Patient Family Member/Friend Healthcare Professional Other Email(Required)Used only if we need clarification PhoneMay we Contact You? You may contact me if more details are needed I prefer to remain anonymous in any public recognition Do you know the EMS professional’s name?(Required) Yes No/Not Sure This field is hidden when viewing the formIf user selects "yes" for About the EMS ProfessionalName of EMS Professional First Last EMS Agency or ServicesExample: AMR, county EMS, fire departmentThis field is hidden when viewing the formIf user selects "no" for About the EMS ProfessionalIncident DetailsThese details help us identify the right EMS professional. Even partial information is helpful.Date of the IncidentMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Approximate Time Early morning Midday Evening Late night Location of the ResponseStreet address, city, or facility nameDo you remember anything about the EMS professional(s)? Uniform color Ambulance or unit number Fire department crew Number of responders Partner/crew details Other Details (optional)Please describe a specific moment or situation that shows how this EMS professional demonstrated excellence. Helpful Prompts: What was happening at the time? What actions did the EMS professional take? How did they treat you or the patient? What made this care stand out? StoryPermissions I understand this nomination may be reviewed for EMS recognition or awards I give permission for this story to be shared (without personal health details) Thank you for taking time to recognize excellence in EMS care.