Star of Life Nomination Form

Name of person submitting nomination.*

First Last

Organization of person submitting nomination.*

Address of person submitting nomination.*

Street Address Address Line 2 City State ZIP Code

Phone number of person uploading nomination.*

E-mail of person uploading nomination.*

Acknowledgement*

I agree to being responsible for ensuring all information in this nomination packet is correct. I understand that I will be responsible for helping the CECA office and the agency director / POC by being their point person to help distribute any unclaimed Award Lapel Pins and Certificates at the end of the Star of Life Award ceremony. If I am unable to attend the event, I will notify the CECA office immediately on who will serve in my place along with that person's contact information.

EMS region being nominated*

Region where incident occurred.

Date of Incident*

Place of Incident*

Patient Information*

Patient's Name	Patient's E-mail	Patient's Phone Number	Patient's Diagnosis

To add multiple patients, please press the + icon at the far right of the row.

In your own words, please provide a written narrative of the EMS run and attach a copy of all EMS run sheets, aeromedical run sheets (if applicable) and emergency department notes.*

EMS run sheets, aeromedical run sheets (if applicable) and emergency department notes.*

Drop files here or

Max. file size: 50 MB.

In your own words, please explain why you think the EMS Star of Life Award should be given to the nominees?*

Please attach the signed patient consent form.*

Drop files here or

Max. file size: 50 MB.

This form can be found on the CECA Website under the Star of Life Award tab.

Agency names to be Engraved on the Granite Stone Award (OPTIONAL for submission - will need this information within two weeks of being selected as your region's winner)

Ensure all agencies are listed and their names are spelled correctly. This list is what will be used to engrave the Stone Awards which will be handed out to each EMS Regional Winner. To add multiple agencies, please press the + icon at the far right of the row.

Agency Director(s)*

Agency	First name	Last name	E-mail	Cell phone

Please list the service director's contact information to help us obtain the contact information for the individuals involved with this run. This person(s) will be the main contact for information about the run and the individuals involved, to include: I agree to being responsible for ensuring all information in this nomination packet is correct, to include: the spelling of all individual names and EMS agencies, all names are included for the individuals associated with this incident and their contact information is accurate. To add multiple service directors or key contacts, please press the + icon at the far right of the row.

Individuals Involved from Dispatch to Hospital Doors (OPTIONAL for submission - will need this information within two weeks of being selected as your region's winner)

Agency	First name	Last name	E-mail	Cell phone

Please list all pre-hospital providers involved with this incident. To add multiple providers, please press the + icon at the far right of the row.

Regional Photos (OPTIONAL for submission - will need this information if selected as your region's winner)

Drop files here or

Max. file size: 50 MB, Max. files: 10.

Photos of the EMS personnel and patients being nominated. Photos to be used in event program and presentation.

Media Contact Form (OPTIONAL - will need this information if selected as your region's winner)

Name of Media Outlet	Point of Contact Name	Address	E-mail	Phone Number

Please list all media and their contact information that you would like the CECA office to invite to the ceremony and supply a press release to at the completion of the event. To add multiple media outlets, please press the + icon at the far right of the row.

Suggestions & Ideas

We continuously strive to improve the Star of Life Award ceremony each year. Please let us know if you have any suggestions or ideas on how we can improve this event.

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