app.smartsheet.com
Open in
urlscan Pro
44.220.98.227
Public Scan
Submitted URL: https://tinyurl.com/2024EMSNominationForm
Effective URL: https://app.smartsheet.com/b/form/5554ee6523ab4138a2b97c7ee637f684
Submission: On May 14 via manual from US — Scanned from DE
Effective URL: https://app.smartsheet.com/b/form/5554ee6523ab4138a2b97c7ee637f684
Submission: On May 14 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
<form>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Divider" data-client-type="divider" class="css-1e2fy0l e14sboee0">
<hr data-client-id="Divider" class="css-1xs1ymt e14sboee2">
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_BEFORE YOU BEGIN" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0">
<h2 data-client-id="heading_BEFORE YOU BEGIN" class="css-1ogntkt e1vg1njp1">BEFORE YOU BEGIN</h2>
</div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Divider" data-client-type="divider" class="css-1e2fy0l e14sboee0">
<hr data-client-id="Divider" class="css-1xs1ymt e14sboee2">
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_undefined" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0"></div>
<p data-client-id="subheading_undefined" class="css-1ey0zoe e1vg1njp2"></p>
<p>Please follow these suggested tips to make your online nomination process run smoothly:</p>
<p><br></p>
<ul>
<li>Gather <a target="_blank" rel="nofollow noreferrer noopener" href="https://www.floridahealth.gov/licensing-and-regulation/ems-system/state-ems-awards.html">all necessary documentation</a> prior to starting the online form as it does not
allow work to be saved.</li>
</ul>
<p><br></p>
<ul>
<li>Write the Summary Statement in a separate document on your computer prior to starting the application process.</li>
</ul>
<p><br></p>
<ul>
<li>Ensure the files that you attach do not exceed the limit (maximum file size for each upload is 250 MB).</li>
</ul>
<p></p>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_undefined" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0"></div>
<p data-client-id="subheading_undefined" class="css-1ey0zoe e1vg1njp2"></p>
<p><br></p>
<p><br></p>
<p></p>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Divider" data-client-type="divider" class="css-1e2fy0l e14sboee0">
<hr data-client-id="Divider" class="css-1xs1ymt e14sboee2">
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_AWARD CATEGORY SELECTION" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0">
<h2 data-client-id="heading_AWARD CATEGORY SELECTION" class="css-1ogntkt e1vg1njp1">AWARD CATEGORY SELECTION</h2>
</div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Divider" data-client-type="divider" class="css-1e2fy0l e14sboee0">
<hr data-client-id="Divider" class="css-1xs1ymt e14sboee2">
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div role="application" title="" data-client-id="container_Award Category" data-client-type="dropdown" id="yZkKZQqYe" class="css-u3yn36 ef83ajd0"><label for="select_input_Award Category" id="8fa96830-79b6-4332-8046-c10e426d83d9"
data-client-id="label_Award Category" class="css-1xl1v40 ekxsfat0">Award Category<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div class="rich-text-field-desc css-1q4upac" id="description_select_input_Award_Category">
<p>Select only one category for each nomination. Nominate only one person, agency, or organization per submission.</p>
</div>
<div class="css-t8xanh-container">
<div class="css-kf2egt-control react-select__control">
<div class="css-11ksah1 react-select__value-container">
<div class="css-1i5h0xy-placeholder react-select__placeholder">Select</div>
<div class="css-1g6gooi">
<div class="react-select__input" style="display: inline-block;"><input autocapitalize="none" autocomplete="off" autocorrect="off" id="select_input_Award Category" spellcheck="false" tabindex="0" type="text" aria-label="Select"
aria-labelledby="8fa96830-79b6-4332-8046-c10e426d83d9" value="" aria-describedby="description_select_input_Award_Category"
style="box-sizing: content-box; width: 2px; background: 0px center; border: 0px; font-size: inherit; opacity: 1; outline: 0px; padding: 0px; color: inherit;">
<div
style="position: absolute; top: 0px; left: 0px; visibility: hidden; height: 0px; overflow: scroll; white-space: pre; font-size: 13px; font-family: Arial; font-weight: 400; font-style: normal; letter-spacing: normal; text-transform: none;">
</div>
</div>
</div>
</div>
<div class="css-1wy0on6 react-select__indicators"><span class="css-9lpq22-indicatorSeparator react-select__indicator-separator"></span><span style="margin-right: 6px;"><svg data-client-id="caret_icon" width="16px" height="16px"
viewBox="0 0 16 16" version="1.1" role="img" xmlns="http://www.w3.org/2000/svg">
<title>Caret Icon</title>
<desc>Caret symbol</desc>
<g stroke="none" stroke-width="1" fill="none" fill-rule="evenodd">
<g fill="#161616">
<path
d="M8.38951287,9.81740951 C8.3743818,9.83527284 8.35811596,9.85207547 8.34082332,9.86770589 C8.12569934,10.0621513 7.79871352,10.0396329 7.61048004,9.81740951 L5.12806062,6.88673235 C5.04550447,6.78926879 5,6.66416424 5,6.53465776 C5,6.23937443 5.23172713,6 5.51757703,6 L10.4824159,6 C10.607785,6 10.7288928,6.04700617 10.8232427,6.13228679 C11.0383667,6.32673222 11.0601658,6.664509 10.8719323,6.88673235 L8.38951287,9.81740951 Z">
</path>
</g>
</g>
</svg></span></div>
</div>
</div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_undefined" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0"></div>
<p data-client-id="subheading_undefined" class="css-1ey0zoe e1vg1njp2"></p>
<p><strong style="color: rgb(255, 153, 0); background-color: rgb(255, 235, 204);"><u>911 Public Safety Telecommunicator</u></strong></p>
<p><br></p>
<p>This award recognizes an <strong>individual </strong>who:</p>
<ul>
<li>has demonstrated outstanding effort in processing a medical emergency call</li>
<li>has demonstrated outstanding efforts in educating the public on 911</li>
</ul>
<p></p>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_undefined" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0"></div>
<p data-client-id="subheading_undefined" class="css-1ey0zoe e1vg1njp2"></p>
<p><strong style="color: rgb(255, 153, 0); background-color: rgb(255, 235, 204);"><u>Emergency Medical Technician</u></strong></p>
<p><br></p>
<p>This award recognizes an <strong>individual </strong>who:</p>
<ul>
<li>is a non-administrative, certified EMT whose primary job is direct patient care</li>
<li>has demonstrated exceptional qualities in one or more of the following areas:</li>
</ul>
<p> • quality assurance/improvement</p>
<p> • patient care</p>
<p> • medical control</p>
<p> • disaster preparedness</p>
<p> • public education and/or training</p>
<ul>
<li>has acted “above and beyond the call of duty” in response to the EMS community and/or profession (please elaborate as to how the individual exceeded normal day-to-day job functions <strong>while on duty</strong>)</li>
</ul>
<p></p>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_undefined" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0"></div>
<p data-client-id="subheading_undefined" class="css-1ey0zoe e1vg1njp2"></p>
<p><strong style="background-color: rgb(255, 235, 204); color: rgb(255, 153, 0);"><u>EMS Education</u></strong></p>
<p><br></p>
<p>This award recognizes an <strong>individual </strong>or <strong>organization </strong>who:</p>
<ul>
<li>is recognized as an educator with a Florida EMS training program, Florida-approved continuing education provider, or licensed EMS service</li>
<li>has assumed a leadership role in the field of EMS education</li>
<li>has made a positive contribution to EMS education in the community, state, or nation</li>
</ul>
<p></p>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_undefined" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0"></div>
<p data-client-id="subheading_undefined" class="css-1ey0zoe e1vg1njp2"></p>
<p><strong style="color: rgb(255, 153, 0); background-color: rgb(255, 235, 204);"><u>EMS Memorial</u></strong></p>
<p><br></p>
<p>This category recognizes all<strong> individuals </strong>who have lost their lives in the line of duty.</p>
<p><br></p>
<p>Please report any of these unfortunate casualties to the EMS program that occurred during the review period. These individuals will be recognized for their sacrifice at the awards ceremony.</p>
<p></p>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_undefined" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0"></div>
<p data-client-id="subheading_undefined" class="css-1ey0zoe e1vg1njp2"></p>
<p><strong style="background-color: rgb(255, 235, 204); color: rgb(255, 153, 0);"><u>EMS Provider</u></strong></p>
<p><br></p>
<p>This award recognizes an <strong>organization</strong> who:</p>
<ul>
<li>is a licensed EMS provider in the state of Florida</li>
<li>participates in the Florida Prehospital EMS Tracking and Reporting System (EMSTARS)</li>
<li>has assumed a leadership role in the Florida EMS system and community</li>
<li>has demonstrated outstanding initiative in the area of public education and/or training</li>
<li>has demonstrated excellence in the areas of quality assurance/improvement and medical control protocol development/implementation</li>
</ul>
<p></p>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_undefined" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0"></div>
<p data-client-id="subheading_undefined" class="css-1ey0zoe e1vg1njp2"></p>
<p><strong style="background-color: rgb(255, 235, 204); color: rgb(255, 153, 0);"><u>EMS Quality Improvement</u></strong></p>
<p><br></p>
<p>This award recognizes an <strong>individual </strong>or <strong>organization</strong> who:</p>
<ul>
<li>is an individual (not limited to licensed individuals), EMS provider, or community partner organization in the state of Florida</li>
<li>has made an outstanding contribution towards the enhancement of patient care or demonstrated exceptional outcomes in their community by using EMSTARS data</li>
<li>has been actively using defined clinical performance or outcomes data to identify opportunities for improvement and documenting the results of improvement efforts</li>
<li>has aligned efforts to achieve measurable improvement in critical clinical outcomes</li>
<li>implemented system changes that achieve high reliability of care processes</li>
<li>has achieved measurable operational or clinical performance improvements that led to higher protocol compliance and/or improved patient outcomes</li>
<li>has made an outstanding contribution to the Florida Emergency Medical Services Advisory Council’s state plan in quality improvement</li>
<li>has developed and implemented innovative approaches in EMS Quality Improvement that have resulted in measurable performance improvement</li>
</ul>
<p></p>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_undefined" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0"></div>
<p data-client-id="subheading_undefined" class="css-1ey0zoe e1vg1njp2"></p>
<p><strong style="background-color: rgb(255, 235, 204); color: rgb(255, 153, 0);"><u>Larry S. Jordan – EMS Hall of Fame</u></strong></p>
<p><br></p>
<p>This award recognizes an <strong>individual </strong>who:</p>
<ul>
<li>is viewed as a national advocate for EMS, increasing public attention and action at the highest levels</li>
<li>has devoted a significant part of his/her life to promoting and advancing prehospital emergency care</li>
<li>has worked to change the manner in which we care for patients throughout the entire continuum of care</li>
<li>has been active on numerous committees and boards at the state level</li>
<li>has had EMS-related works published in journals, textbooks, or other publications</li>
</ul>
<p></p>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_undefined" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0"></div>
<p data-client-id="subheading_undefined" class="css-1ey0zoe e1vg1njp2"></p>
<p><strong style="color: rgb(255, 153, 0); background-color: rgb(255, 235, 204);"><u>Marilyn Crook – EMS Pioneer Award</u></strong></p>
<p><br></p>
<p>This award recognizes an <strong>individual </strong>who has advanced the EMS profession and/or system:</p>
<ul>
<li>through visionary leadership by setting directions and creating patient focus, clear and visible values, and high expectations while balancing the needs of all EMS stakeholders</li>
<li>through visionary leadership by ensuring the creation of strategies, systems, and methods for achieving performance excellence, stimulating innovation, building knowledge and capabilities, and ensuring EMS sustainability</li>
<li>through managing for innovation (innovation means making meaningful changes to improve EMS products, services, programs, processes, and operations and to create new value for EMS stakeholders)</li>
<li>by promoting the use of best practices by building internal and external partnerships to address common issues, enhance communication, and evaluate progress to adapt to changing conditions in the EMS system</li>
</ul>
<p></p>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_undefined" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0"></div>
<p data-client-id="subheading_undefined" class="css-1ey0zoe e1vg1njp2"></p>
<p><strong style="color: rgb(255, 153, 0); background-color: rgb(255, 235, 204);"><u>Mobile Integrated Health</u></strong></p>
<p><br></p>
<p>This award recognizes an <strong>individual or organization</strong> who:</p>
<ul>
<li>is an individual, established EMS-based Mobile Integrated Health provider, or community partner organization in Florida</li>
<li>has made an outstanding contribution or demonstrated exceptional outcomes improving the health of their community with a special emphasis on mental health, substance abuse, high system utilization, general health and wellness, fall
prevention, community education, and prevention programs</li>
<li>has made an outstanding contribution or demonstrated exceptional outcomes working with primary care providers and mental health (including substance use dependence) resources and/or care options for high-risk patient populations to reduce
the burden these individuals have on community systems</li>
<li>has made an outstanding contribution to their state/community to connect medically and socially vulnerable populations to high quality healthcare services</li>
</ul>
<p><br></p>
<p>Please include:</p>
<ul>
<li>how the individual or organization’s innovative approach to collaboration through the use of telehealth and/or other programs has been implemented to address clinical issues and patient needs, as well as provide support, resources, and
education</li>
<li>how the individual or organization participated in the collaboration</li>
<li>how the initiative was identified as a need in the community</li>
<li>how the individual or organization demonstrated qualitative and/or quantitative outcomes that explain how the initiative is successfully addressing clinical issues and patient needs, as well as providing support, resources, and education
to improve population health (if applicable)</li>
</ul>
<p></p>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_undefined" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0"></div>
<p data-client-id="subheading_undefined" class="css-1ey0zoe e1vg1njp2"></p>
<p><strong style="background-color: rgb(255, 235, 204); color: rgb(255, 153, 0);"><u>Paramedic</u></strong></p>
<p><br></p>
<p>This award recognizes an <strong>individual </strong>who:</p>
<ul>
<li>is a non-administrative, certified paramedic whose primary job is direct patient care</li>
<li>has demonstrated exceptional qualities in one or more of the following areas:</li>
</ul>
<p> • quality assurance/improvement</p>
<p> • patient care</p>
<p> • medical control</p>
<p> • disaster preparedness</p>
<p> • public education and/or training</p>
<ul>
<li>has acted “above and beyond the call of duty” in response to the EMS community and/or profession (please elaborate as to how the individual exceeded normal day-to-day job functions)</li>
</ul>
<p></p>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_undefined" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0"></div>
<p data-client-id="subheading_undefined" class="css-1ey0zoe e1vg1njp2"></p>
<p><strong style="color: rgb(255, 153, 0); background-color: rgb(255, 235, 204);"><u>Raymond H. Alexander – EMS Medical Direction</u></strong></p>
<p><br></p>
<p>This award recognizes an <strong>individual </strong>who:</p>
<ul>
<li>is a licensed Florida physician</li>
<li>has assumed a leadership role in EMS within the community or state</li>
<li>has demonstrated excellence in the areas of quality assurance/improvement and medical control</li>
<li>has successfully promoted the use of new medical trends and technologies</li>
</ul>
<p></p>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_undefined" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0"></div>
<p data-client-id="subheading_undefined" class="css-1ey0zoe e1vg1njp2"></p>
<p><br></p>
<p><br></p>
<p></p>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Divider" data-client-type="divider" class="css-1e2fy0l e14sboee0">
<hr data-client-id="Divider" class="css-1xs1ymt e14sboee2">
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_NOMINEE INFORMATION" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0">
<h2 data-client-id="heading_NOMINEE INFORMATION" class="css-1ogntkt e1vg1njp1">NOMINEE INFORMATION</h2>
</div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Divider" data-client-type="divider" class="css-1e2fy0l e14sboee0">
<hr data-client-id="Divider" class="css-1xs1ymt e14sboee2">
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div role="application" title="" data-client-id="container_Select a Nomination Type" data-client-type="dropdown" id="wN0YNdMkY" class="css-u3yn36 ef83ajd0"><label for="select_input_Select a Nomination Type"
id="add19b1c-d582-47e5-9713-55dfd4ff1899" data-client-id="label_Select a Nomination Type" class="css-1xl1v40 ekxsfat0">Select a Nomination Type<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div class="css-t8xanh-container">
<div class="css-kf2egt-control react-select__control">
<div class="css-11ksah1 react-select__value-container">
<div class="css-1i5h0xy-placeholder react-select__placeholder">Select or enter value</div>
<div class="css-1g6gooi">
<div class="react-select__input" style="display: inline-block;"><input autocapitalize="none" autocomplete="off" autocorrect="off" id="select_input_Select a Nomination Type" spellcheck="false" tabindex="0" type="text"
aria-label="Select or enter value" aria-labelledby="add19b1c-d582-47e5-9713-55dfd4ff1899" value=""
style="box-sizing: content-box; width: 2px; background: 0px center; border: 0px; font-size: inherit; opacity: 1; outline: 0px; padding: 0px; color: inherit;">
<div
style="position: absolute; top: 0px; left: 0px; visibility: hidden; height: 0px; overflow: scroll; white-space: pre; font-size: 13px; font-family: Arial; font-weight: 400; font-style: normal; letter-spacing: normal; text-transform: none;">
</div>
</div>
</div>
</div>
<div class="css-1wy0on6 react-select__indicators"><span class="css-9lpq22-indicatorSeparator react-select__indicator-separator"></span><span style="margin-right: 6px;"><svg data-client-id="caret_icon" width="16px" height="16px"
viewBox="0 0 16 16" version="1.1" role="img" xmlns="http://www.w3.org/2000/svg">
<title>Caret Icon</title>
<desc>Caret symbol</desc>
<g stroke="none" stroke-width="1" fill="none" fill-rule="evenodd">
<g fill="#161616">
<path
d="M8.38951287,9.81740951 C8.3743818,9.83527284 8.35811596,9.85207547 8.34082332,9.86770589 C8.12569934,10.0621513 7.79871352,10.0396329 7.61048004,9.81740951 L5.12806062,6.88673235 C5.04550447,6.78926879 5,6.66416424 5,6.53465776 C5,6.23937443 5.23172713,6 5.51757703,6 L10.4824159,6 C10.607785,6 10.7288928,6.04700617 10.8232427,6.13228679 C11.0383667,6.32673222 11.0601658,6.664509 10.8719323,6.88673235 L8.38951287,9.81740951 Z">
</path>
</g>
</g>
</svg></span></div>
</div>
</div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_First Name" data-client-type="text" id="2wkjwXnPl" class="css-1e3khfm ef83ajd0"><label for="text_box_First Name" data-client-id="label_First Name" class="css-1xl1v40 ekxsfat0">First Name<span
data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="-1" id="text_box_First Name" data-testid="text_box_First Name" data-client-id="text_box_First Name" data-client-type="" name="2wkjwXnPl" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_Last Name" data-client-type="text" id="zAXgA8RLA" class="css-1e3khfm ef83ajd0"><label for="text_box_Last Name" data-client-id="label_Last Name" class="css-1xl1v40 ekxsfat0">Last Name<span
data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="-1" id="text_box_Last Name" data-testid="text_box_Last Name" data-client-id="text_box_Last Name" data-client-type="" name="zAXgA8RLA" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_Organization Name" data-client-type="text" id="Z5Rj5reQ6" class="css-1e3khfm ef83ajd0"><label for="text_box_Organization Name" data-client-id="label_Organization Name" class="css-1xl1v40 ekxsfat0">Organization
Name<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="-1" id="text_box_Organization Name" data-testid="text_box_Organization Name" data-client-id="text_box_Organization Name" data-client-type="" name="Z5Rj5reQ6"
maxlength="4000" class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div role="application" title="" data-client-id="container_Organization County" data-client-type="dropdown" id="J9nA9Dd00" class="css-u3yn36 ef83ajd0"><label for="select_input_Organization County" id="0492214a-5f20-4ecd-b482-db51281bbb16"
data-client-id="label_Organization County" class="css-1xl1v40 ekxsfat0">Organization County<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div class="css-t8xanh-container">
<div class="css-kf2egt-control react-select__control">
<div class="css-11ksah1 react-select__value-container">
<div class="css-1i5h0xy-placeholder react-select__placeholder">Select</div>
<div class="css-1g6gooi">
<div class="react-select__input" style="display: inline-block;"><input autocapitalize="none" autocomplete="off" autocorrect="off" id="select_input_Organization County" spellcheck="false" tabindex="-1" type="text" aria-label="Select"
aria-labelledby="0492214a-5f20-4ecd-b482-db51281bbb16" value="" style="box-sizing: content-box; width: 2px; background: 0px center; border: 0px; font-size: inherit; opacity: 1; outline: 0px; padding: 0px; color: inherit;">
<div
style="position: absolute; top: 0px; left: 0px; visibility: hidden; height: 0px; overflow: scroll; white-space: pre; font-size: 13px; font-family: Arial; font-weight: 400; font-style: normal; letter-spacing: normal; text-transform: none;">
</div>
</div>
</div>
</div>
<div class="css-1wy0on6 react-select__indicators"><span class="css-9lpq22-indicatorSeparator react-select__indicator-separator"></span><span style="margin-right: 6px;"><svg data-client-id="caret_icon" width="16px" height="16px"
viewBox="0 0 16 16" version="1.1" role="img" xmlns="http://www.w3.org/2000/svg">
<title>Caret Icon</title>
<desc>Caret symbol</desc>
<g stroke="none" stroke-width="1" fill="none" fill-rule="evenodd">
<g fill="#161616">
<path
d="M8.38951287,9.81740951 C8.3743818,9.83527284 8.35811596,9.85207547 8.34082332,9.86770589 C8.12569934,10.0621513 7.79871352,10.0396329 7.61048004,9.81740951 L5.12806062,6.88673235 C5.04550447,6.78926879 5,6.66416424 5,6.53465776 C5,6.23937443 5.23172713,6 5.51757703,6 L10.4824159,6 C10.607785,6 10.7288928,6.04700617 10.8232427,6.13228679 C11.0383667,6.32673222 11.0601658,6.664509 10.8719323,6.88673235 L8.38951287,9.81740951 Z">
</path>
</g>
</g>
</svg></span></div>
</div>
</div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_Address Line 1" data-client-type="text" id="1z18zLvPL" class="css-1e3khfm ef83ajd0"><label for="text_box_Address Line 1" data-client-id="label_Address Line 1" class="css-1xl1v40 ekxsfat0">Address Line 1</label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="-1" id="text_box_Address Line 1" data-testid="text_box_Address Line 1" data-client-id="text_box_Address Line 1" data-client-type="" name="1z18zLvPL" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_Address Line 2" data-client-type="text" id="LQo9QNKGg" class="css-1e3khfm ef83ajd0"><label for="text_box_Address Line 2" data-client-id="label_Address Line 2" class="css-1xl1v40 ekxsfat0">Address Line 2</label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="-1" id="text_box_Address Line 2" data-testid="text_box_Address Line 2" data-client-id="text_box_Address Line 2" data-client-type="" name="LQo9QNKGg" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div role="application" title="" data-client-id="container_City" data-client-type="dropdown" id="X0EQ0WOPD" class="css-u3yn36 ef83ajd0"><label for="select_input_City" id="e831591c-5331-4b30-bf41-c54fe822d306" data-client-id="label_City"
class="css-1xl1v40 ekxsfat0">City</label>
<div class="css-t8xanh-container">
<div class="css-kf2egt-control react-select__control">
<div class="css-11ksah1 react-select__value-container">
<div class="css-1i5h0xy-placeholder react-select__placeholder">Select</div>
<div class="css-1g6gooi">
<div class="react-select__input" style="display: inline-block;"><input autocapitalize="none" autocomplete="off" autocorrect="off" id="select_input_City" spellcheck="false" tabindex="-1" type="text" aria-label="Select"
aria-labelledby="e831591c-5331-4b30-bf41-c54fe822d306" value="" style="box-sizing: content-box; width: 2px; background: 0px center; border: 0px; font-size: inherit; opacity: 1; outline: 0px; padding: 0px; color: inherit;">
<div
style="position: absolute; top: 0px; left: 0px; visibility: hidden; height: 0px; overflow: scroll; white-space: pre; font-size: 13px; font-family: Arial; font-weight: 400; font-style: normal; letter-spacing: normal; text-transform: none;">
</div>
</div>
</div>
</div>
<div class="css-1wy0on6 react-select__indicators"><span class="css-9lpq22-indicatorSeparator react-select__indicator-separator"></span><span style="margin-right: 6px;"><svg data-client-id="caret_icon" width="16px" height="16px"
viewBox="0 0 16 16" version="1.1" role="img" xmlns="http://www.w3.org/2000/svg">
<title>Caret Icon</title>
<desc>Caret symbol</desc>
<g stroke="none" stroke-width="1" fill="none" fill-rule="evenodd">
<g fill="#161616">
<path
d="M8.38951287,9.81740951 C8.3743818,9.83527284 8.35811596,9.85207547 8.34082332,9.86770589 C8.12569934,10.0621513 7.79871352,10.0396329 7.61048004,9.81740951 L5.12806062,6.88673235 C5.04550447,6.78926879 5,6.66416424 5,6.53465776 C5,6.23937443 5.23172713,6 5.51757703,6 L10.4824159,6 C10.607785,6 10.7288928,6.04700617 10.8232427,6.13228679 C11.0383667,6.32673222 11.0601658,6.664509 10.8719323,6.88673235 L8.38951287,9.81740951 Z">
</path>
</g>
</g>
</svg></span></div>
</div>
</div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_City - Other (not listed above)" data-client-type="text" id="rj5vjZbPg" class="css-1e3khfm ef83ajd0"><label for="text_box_City - Other (not listed above)" data-client-id="label_City - Other (not listed above)"
class="css-1xl1v40 ekxsfat0">City - Other (not listed above)<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="-1" id="text_box_City - Other (not listed above)" data-testid="text_box_City - Other (not listed above)" data-client-id="text_box_City - Other (not listed above)"
data-client-type="" name="rj5vjZbPg" maxlength="4000" class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_State" data-client-type="text" id="0wkQwdpnL" class="css-1e3khfm ef83ajd0"><label for="text_box_State" data-client-id="label_State" class="css-1xl1v40 ekxsfat0">State</label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="-1" id="text_box_State" data-testid="text_box_State" data-client-id="text_box_State" data-client-type="" name="0wkQwdpnL" maxlength="4000" class="css-1p0590h e1407lhe0"
value=""></div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_Zip" data-client-type="text" id="7wkdwX81k" class="css-1e3khfm ef83ajd0"><label for="text_box_Zip" data-client-id="label_Zip" class="css-1xl1v40 ekxsfat0">Zip</label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="-1" id="text_box_Zip" data-testid="text_box_Zip" data-client-id="text_box_Zip" data-client-type="" name="7wkdwX81k" maxlength="4000" class="css-1p0590h e1407lhe0"
value=""></div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_Phone" data-client-type="text" id="Ky1AyO9Y3" class="css-1e3khfm ef83ajd0"><label for="text_box_Phone" data-client-id="label_Phone" class="css-1xl1v40 ekxsfat0">Phone</label>
<div style="display: flex;">
<div class=" react-tel-input" style="height: 35px; width: 40px;">
<div class="special-label">Phone</div><input class=" form-control" placeholder="1 (702) 123-4567" type="tel" name="Ky1AyO9Y3" aria-hidden="true" aria-label="phone picker" value="+1" style="display: none;">
<div class=" flag-dropdown">
<div class="selected-flag" title="United States: + 1" tabindex="0" role="button" aria-haspopup="listbox">
<div class="flag us">
<div class="arrow"></div>
</div>
</div>
</div>
</div><input aria-invalid="false" tabindex="-1" id="text_box_Phone" data-client-id="text_box_Phone" data-client-type="PHONE" type="text" value="+1 (___) ___-____" inputmode="numeric">
</div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_Email" data-client-type="text" id="yZkKZQqYp" class="css-1e3khfm ef83ajd0"><label for="text_box_Email" data-client-id="label_Email" class="css-1xl1v40 ekxsfat0">Email</label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="-1" id="text_box_Email" data-testid="text_box_Email" data-client-id="text_box_Email" data-client-type="EMAIL" name="yZkKZQqYp" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_undefined" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0"></div>
<p data-client-id="subheading_undefined" class="css-1ey0zoe e1vg1njp2"></p>
<p><br></p>
<p><br></p>
<p></p>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Divider" data-client-type="divider" class="css-1e2fy0l e14sboee0">
<hr data-client-id="Divider" class="css-1xs1ymt e14sboee2">
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_NOMINATION SUBMITTED BY" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0">
<h2 data-client-id="heading_NOMINATION SUBMITTED BY" class="css-1ogntkt e1vg1njp1">NOMINATION SUBMITTED BY</h2>
</div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Divider" data-client-type="divider" class="css-1e2fy0l e14sboee0">
<hr data-client-id="Divider" class="css-1xs1ymt e14sboee2">
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_First Name" data-client-type="text" id="80k70nj5G" class="css-1e3khfm ef83ajd0"><label for="text_box_First Name" data-client-id="label_First Name" class="css-1xl1v40 ekxsfat0">First Name<span
data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_First Name" data-testid="text_box_First Name" data-client-id="text_box_First Name" data-client-type="" name="80k70nj5G" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Last Name" data-client-type="text" id="QDl7DWydX" class="css-1e3khfm ef83ajd0"><label for="text_box_Last Name" data-client-id="label_Last Name" class="css-1xl1v40 ekxsfat0">Last Name<span
data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Last Name" data-testid="text_box_Last Name" data-client-id="text_box_Last Name" data-client-type="" name="QDl7DWydX" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Organization Name (if applicable)" data-client-type="text" id="jXEmXqna3" class="css-1e3khfm ef83ajd0"><label for="text_box_Organization Name (if applicable)" data-client-id="label_Organization Name (if applicable)"
class="css-1xl1v40 ekxsfat0">Organization Name (if applicable)</label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Organization Name (if applicable)" data-testid="text_box_Organization Name (if applicable)" data-client-id="text_box_Organization Name (if applicable)"
data-client-type="" name="jXEmXqna3" maxlength="4000" class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Address Line 1" data-client-type="text" id="lXRmXGga1" class="css-1e3khfm ef83ajd0"><label for="text_box_Address Line 1" data-client-id="label_Address Line 1" class="css-1xl1v40 ekxsfat0">Address Line 1</label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Address Line 1" data-testid="text_box_Address Line 1" data-client-id="text_box_Address Line 1" data-client-type="" name="lXRmXGga1" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Address Line 2" data-client-type="text" id="bEjnElaeL" class="css-1e3khfm ef83ajd0"><label for="text_box_Address Line 2" data-client-id="label_Address Line 2" class="css-1xl1v40 ekxsfat0">Address Line 2</label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Address Line 2" data-testid="text_box_Address Line 2" data-client-id="text_box_Address Line 2" data-client-type="" name="bEjnElaeL" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div role="application" title="" data-client-id="container_City" data-client-type="dropdown" id="D0od0y6GR" class="css-u3yn36 ef83ajd0"><label for="select_input_City" id="6eec31d4-71c1-487f-92a9-bbc911d5bbe2" data-client-id="label_City"
class="css-1xl1v40 ekxsfat0">City</label>
<div class="css-t8xanh-container">
<div class="css-kf2egt-control react-select__control">
<div class="css-11ksah1 react-select__value-container">
<div class="css-1i5h0xy-placeholder react-select__placeholder">Select</div>
<div class="css-1g6gooi">
<div class="react-select__input" style="display: inline-block;"><input autocapitalize="none" autocomplete="off" autocorrect="off" id="select_input_City" spellcheck="false" tabindex="0" type="text" aria-label="Select"
aria-labelledby="6eec31d4-71c1-487f-92a9-bbc911d5bbe2" value="" style="box-sizing: content-box; width: 2px; background: 0px center; border: 0px; font-size: inherit; opacity: 1; outline: 0px; padding: 0px; color: inherit;">
<div
style="position: absolute; top: 0px; left: 0px; visibility: hidden; height: 0px; overflow: scroll; white-space: pre; font-size: 13px; font-family: Arial; font-weight: 400; font-style: normal; letter-spacing: normal; text-transform: none;">
</div>
</div>
</div>
</div>
<div class="css-1wy0on6 react-select__indicators"><span class="css-9lpq22-indicatorSeparator react-select__indicator-separator"></span><span style="margin-right: 6px;"><svg data-client-id="caret_icon" width="16px" height="16px"
viewBox="0 0 16 16" version="1.1" role="img" xmlns="http://www.w3.org/2000/svg">
<title>Caret Icon</title>
<desc>Caret symbol</desc>
<g stroke="none" stroke-width="1" fill="none" fill-rule="evenodd">
<g fill="#161616">
<path
d="M8.38951287,9.81740951 C8.3743818,9.83527284 8.35811596,9.85207547 8.34082332,9.86770589 C8.12569934,10.0621513 7.79871352,10.0396329 7.61048004,9.81740951 L5.12806062,6.88673235 C5.04550447,6.78926879 5,6.66416424 5,6.53465776 C5,6.23937443 5.23172713,6 5.51757703,6 L10.4824159,6 C10.607785,6 10.7288928,6.04700617 10.8232427,6.13228679 C11.0383667,6.32673222 11.0601658,6.664509 10.8719323,6.88673235 L8.38951287,9.81740951 Z">
</path>
</g>
</g>
</svg></span></div>
</div>
</div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_City - Other (not listed above)" data-client-type="text" id="Ol8glEWwZ" class="css-1e3khfm ef83ajd0"><label for="text_box_City - Other (not listed above)" data-client-id="label_City - Other (not listed above)"
class="css-1xl1v40 ekxsfat0">City - Other (not listed above)<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="-1" id="text_box_City - Other (not listed above)" data-testid="text_box_City - Other (not listed above)" data-client-id="text_box_City - Other (not listed above)"
data-client-type="" name="Ol8glEWwZ" maxlength="4000" class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_State" data-client-type="text" id="NjQdjMnPn" class="css-1e3khfm ef83ajd0"><label for="text_box_State" data-client-id="label_State" class="css-1xl1v40 ekxsfat0">State</label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_State" data-testid="text_box_State" data-client-id="text_box_State" data-client-type="" name="NjQdjMnPn" maxlength="4000" class="css-1p0590h e1407lhe0"
value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Zip" data-client-type="text" id="epDzpO5ng" class="css-1e3khfm ef83ajd0"><label for="text_box_Zip" data-client-id="label_Zip" class="css-1xl1v40 ekxsfat0">Zip</label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Zip" data-testid="text_box_Zip" data-client-id="text_box_Zip" data-client-type="" name="epDzpO5ng" maxlength="4000" class="css-1p0590h e1407lhe0"
value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Phone" data-client-type="text" id="M8yL8ev07" class="css-1e3khfm ef83ajd0"><label for="text_box_Phone" data-client-id="label_Phone" class="css-1xl1v40 ekxsfat0">Phone</label>
<div style="display: flex;">
<div class=" react-tel-input" style="height: 35px; width: 40px;">
<div class="special-label">Phone</div><input class=" form-control" placeholder="1 (702) 123-4567" type="tel" name="M8yL8ev07" aria-hidden="true" aria-label="phone picker" value="+1" style="display: none;">
<div class=" flag-dropdown">
<div class="selected-flag" title="United States: + 1" tabindex="0" role="button" aria-haspopup="listbox">
<div class="flag us">
<div class="arrow"></div>
</div>
</div>
</div>
</div><input aria-invalid="false" tabindex="0" id="text_box_Phone" data-client-id="text_box_Phone" data-client-type="PHONE" type="text" value="+1 (___) ___-____" inputmode="numeric">
</div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Email" data-client-type="text" id="EPzJPQ3nN" class="css-1e3khfm ef83ajd0"><label for="text_box_Email" data-client-id="label_Email" class="css-1xl1v40 ekxsfat0">Email</label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Email" data-testid="text_box_Email" data-client-id="text_box_Email" data-client-type="EMAIL" name="EPzJPQ3nN" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_undefined" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0"></div>
<p data-client-id="subheading_undefined" class="css-1ey0zoe e1vg1njp2"></p>
<p><br></p>
<p><br></p>
<p></p>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Divider" data-client-type="divider" class="css-1e2fy0l e14sboee0">
<hr data-client-id="Divider" class="css-1xs1ymt e14sboee2">
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_SUMMARY STATEMENT" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0">
<h2 data-client-id="heading_SUMMARY STATEMENT" class="css-1ogntkt e1vg1njp1">SUMMARY STATEMENT</h2>
</div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Divider" data-client-type="divider" class="css-1e2fy0l e14sboee0">
<hr data-client-id="Divider" class="css-1xs1ymt e14sboee2">
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Summary Statement" data-client-type="text" id="QDl7DWydY" class="css-1e3khfm ef83ajd0"><label for="textarea_Summary Statement" data-client-id="label_Summary Statement" class="css-1xl1v40 ekxsfat0">Summary
Statement<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div id="description_Summary_Statement" class="rich-text-field-desc">
<p>Prepare a summary statement describing how the nominee meets the award criteria, depicting the nominee’s qualities and contributions to EMS in Florida.</p>
<p><br></p>
<p>Include why the nominee is exceptionally qualified and should be selected for this award. Break down the nomination criteria and describe in detail how the nominee has excelled in each area. </p>
</div><textarea aria-invalid="false" aria-describedby="description_Summary_Statement" tabindex="0" name="QDl7DWydY" id="textarea_Summary Statement" data-client-id="textarea_Summary Statement" maxlength="4000" rows="20"
class="css-1lh64kx e1407lhe1"></textarea>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_undefined" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0"></div>
<p data-client-id="subheading_undefined" class="css-1ey0zoe e1vg1njp2"></p>
<p><br></p>
<p><br></p>
<p></p>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Divider" data-client-type="divider" class="css-1e2fy0l e14sboee0">
<hr data-client-id="Divider" class="css-1xs1ymt e14sboee2">
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_ATTACHMENTS" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0">
<h2 data-client-id="heading_ATTACHMENTS" class="css-1ogntkt e1vg1njp1">ATTACHMENTS</h2>
</div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Divider" data-client-type="divider" class="css-1e2fy0l e14sboee0">
<hr data-client-id="Divider" class="css-1xs1ymt e14sboee2">
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_File Upload" data-client-type="file_upload" id="ATTACHMENT" class="css-1ylo82b ef83ajd0"><label for="file_upload_File Upload" data-client-id="label_File Upload" class="css-1xl1v40 ekxsfat0">File Upload<span
data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div class="rich-text-field-desc css-i0kenq" id="description_file_upload_File_Upload">
<p>Please attach the following for each submission:</p>
<p><br></p>
<ul>
<li><strong>Supporting Materials:</strong> Submit any materials to support the candidate’s nomination that you deem necessary, such as articles, letters, resumé, audio recordings, photographs, or additional documentation.</li>
</ul>
<p><br></p>
<ul>
<li><strong>Electronic Photograph </strong><strong style="color: rgb(102, 163, 224);">[required]</strong><strong>: </strong>Submit an electronic photograph (high-resolution JPEG) of the nominee. This photo will be incorporated into the
awards ceremony in the event the nominee is selected as a winner.</li>
</ul>
<p><br></p>
<ul>
<li><strong>Signed Release Form(s) </strong><strong style="color: rgb(102, 163, 224);">[required]</strong><strong>: </strong>Submit the completed
<a rel="nofollow noreferrer noopener" href="https://gcc02.safelinks.protection.outlook.com/ap/b-59584e83/?url=https%3A%2F%2Ffloridahealth.sharepoint.com%2Fsites%2FCOMMUNICATIONS%2FShared%2520Documents%2FPhoto_Release_English.pdf&data=05%7C01%7CEdmund.Mills%40flhealth.gov%7Cf6b5e53b87b24afbf4aa08daf49ecd87%7C28cd8f803c444b2781a0cd2b03a31b8d%7C0%7C0%7C638091260141946043%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=QAox76uclt6yOjx5wvIjyzblNdihlaxKGOcR36WVgJY%3D&reserved=0">photo release form(s)</a>
signed by the individual or organization.</li>
</ul>
<p><br></p>
<p><br></p>
</div>
<div class="css-vqlje4" tabindex="0" data-client-id="file_upload_dropzone" aria-describedby="description_file_upload_File_Upload" aria-disabled="false" style="position: relative;">
<div class="css-hvudvc eo18oon8"><span class="css-1btvv3a eo18oon1"><span>Drag and drop files here or </span> <button tabindex="0" type="button" class="css-uro7iq eo18oon0"><span>browse files</span></button></span></div><input
id="file_upload_File Upload" tabindex="0" type="file" multiple="" autocomplete="off" style="position: absolute; inset: 0px; opacity: 1e-05; pointer-events: none;">
</div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_undefined" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0"></div>
<p data-client-id="subheading_undefined" class="css-1ey0zoe e1vg1njp2"></p>
<p><br></p>
<p><br></p>
<p></p>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Divider" data-client-type="divider" class="css-1e2fy0l e14sboee0">
<hr data-client-id="Divider" class="css-1xs1ymt e14sboee2">
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_GUIDELINES" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0">
<h2 data-client-id="heading_GUIDELINES" class="css-1ogntkt e1vg1njp1">GUIDELINES</h2>
</div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Divider" data-client-type="divider" class="css-1e2fy0l e14sboee0">
<hr data-client-id="Divider" class="css-1xs1ymt e14sboee2">
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_undefined" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0"></div>
<p data-client-id="subheading_undefined" class="css-1ey0zoe e1vg1njp2"></p>
<p>In order to be considered for an EMS Award:</p>
<p><br></p>
<ul>
<li>A nominee cannot have any administrative actions pending with the Florida Department of Health.</li>
</ul>
<p><br></p>
<ul>
<li>All of the necessary information and supporting documentation must be provided.</li>
</ul>
<p><br></p>
<p><br></p>
<p></p>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_undefined" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0"></div>
<p data-client-id="subheading_undefined" class="css-1ey0zoe e1vg1njp2"></p>
<p><strong>The deadline for the 2024 State EMS Award nominations is Sunday, June 30, 2024.</strong></p>
<p></p>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="email_receipt_section">
<div data-client-id="container_email_receipt" data-client-type="divider" class="css-1e2fy0l e14sboee0">
<hr data-client-id="email_receipt" class="css-1xs1ymt e14sboee2">
</div>
<div class="css-1gl0c9l excyp8g0"><label class="css-1y93uaa excyp8g1"><input data-client-id="email_receipt_checkbox" name="EMAIL_RECEIPT_CHECKBOX" type="checkbox" class="css-1czgm8r excyp8g2" value="false"><span>Send me a copy of my
responses</span></label></div>
</div>
</div>
<div class="css-1ock8o4 e1xpzprc2"><button data-client-id="form_submit_btn" disabled="" type="submit" value="submit" class="css-oltpmt e1xpzprc0"><span>Submit</span></button></div>
<div data-client-id="footer" class="css-ybae4b e8i4qwl0">
<div class="css-1kw6mnl e8i4qwl1"><a target="_blank" href="https://www.smartsheet.com/legal/privacy" rel="noopener noreferrer" data-client-id="footer_privacy" class="css-a7ff3e e8i4qwl2"><span>Privacy Notice</span></a><span
style="margin: 0px 5px;">|</span><a target="_blank" href="https://app.smartsheet.com/b/reportabuse?EQBCT=5554ee6523ab4138a2b97c7ee637f684" rel="noopener noreferrer" data-client-id="footer_reportAbuse" class="css-a7ff3e e8i4qwl2"><span>Report Abuse</span></a>
</div>
</div>
</form>Text Content
2024 NOMINATION FORM FLORIDA DEPARTMENT OF HEALTH EMERGENCY MEDICAL SERVICES STATE EMS AWARDS -------------------------------------------------------------------------------- BEFORE YOU BEGIN -------------------------------------------------------------------------------- Please follow these suggested tips to make your online nomination process run smoothly: * Gather all necessary documentation prior to starting the online form as it does not allow work to be saved. * Write the Summary Statement in a separate document on your computer prior to starting the application process. * Ensure the files that you attach do not exceed the limit (maximum file size for each upload is 250 MB). -------------------------------------------------------------------------------- AWARD CATEGORY SELECTION -------------------------------------------------------------------------------- Award Category* Select only one category for each nomination. Nominate only one person, agency, or organization per submission. Select Caret IconCaret symbol 911 Public Safety Telecommunicator This award recognizes an individual who: * has demonstrated outstanding effort in processing a medical emergency call * has demonstrated outstanding efforts in educating the public on 911 Emergency Medical Technician This award recognizes an individual who: * is a non-administrative, certified EMT whose primary job is direct patient care * has demonstrated exceptional qualities in one or more of the following areas: • quality assurance/improvement • patient care • medical control • disaster preparedness • public education and/or training * has acted “above and beyond the call of duty” in response to the EMS community and/or profession (please elaborate as to how the individual exceeded normal day-to-day job functions while on duty) EMS Education This award recognizes an individual or organization who: * is recognized as an educator with a Florida EMS training program, Florida-approved continuing education provider, or licensed EMS service * has assumed a leadership role in the field of EMS education * has made a positive contribution to EMS education in the community, state, or nation EMS Memorial This category recognizes all individuals who have lost their lives in the line of duty. Please report any of these unfortunate casualties to the EMS program that occurred during the review period. These individuals will be recognized for their sacrifice at the awards ceremony. EMS Provider This award recognizes an organization who: * is a licensed EMS provider in the state of Florida * participates in the Florida Prehospital EMS Tracking and Reporting System (EMSTARS) * has assumed a leadership role in the Florida EMS system and community * has demonstrated outstanding initiative in the area of public education and/or training * has demonstrated excellence in the areas of quality assurance/improvement and medical control protocol development/implementation EMS Quality Improvement This award recognizes an individual or organization who: * is an individual (not limited to licensed individuals), EMS provider, or community partner organization in the state of Florida * has made an outstanding contribution towards the enhancement of patient care or demonstrated exceptional outcomes in their community by using EMSTARS data * has been actively using defined clinical performance or outcomes data to identify opportunities for improvement and documenting the results of improvement efforts * has aligned efforts to achieve measurable improvement in critical clinical outcomes * implemented system changes that achieve high reliability of care processes * has achieved measurable operational or clinical performance improvements that led to higher protocol compliance and/or improved patient outcomes * has made an outstanding contribution to the Florida Emergency Medical Services Advisory Council’s state plan in quality improvement * has developed and implemented innovative approaches in EMS Quality Improvement that have resulted in measurable performance improvement Larry S. Jordan – EMS Hall of Fame This award recognizes an individual who: * is viewed as a national advocate for EMS, increasing public attention and action at the highest levels * has devoted a significant part of his/her life to promoting and advancing prehospital emergency care * has worked to change the manner in which we care for patients throughout the entire continuum of care * has been active on numerous committees and boards at the state level * has had EMS-related works published in journals, textbooks, or other publications Marilyn Crook – EMS Pioneer Award This award recognizes an individual who has advanced the EMS profession and/or system: * through visionary leadership by setting directions and creating patient focus, clear and visible values, and high expectations while balancing the needs of all EMS stakeholders * through visionary leadership by ensuring the creation of strategies, systems, and methods for achieving performance excellence, stimulating innovation, building knowledge and capabilities, and ensuring EMS sustainability * through managing for innovation (innovation means making meaningful changes to improve EMS products, services, programs, processes, and operations and to create new value for EMS stakeholders) * by promoting the use of best practices by building internal and external partnerships to address common issues, enhance communication, and evaluate progress to adapt to changing conditions in the EMS system Mobile Integrated Health This award recognizes an individual or organization who: * is an individual, established EMS-based Mobile Integrated Health provider, or community partner organization in Florida * has made an outstanding contribution or demonstrated exceptional outcomes improving the health of their community with a special emphasis on mental health, substance abuse, high system utilization, general health and wellness, fall prevention, community education, and prevention programs * has made an outstanding contribution or demonstrated exceptional outcomes working with primary care providers and mental health (including substance use dependence) resources and/or care options for high-risk patient populations to reduce the burden these individuals have on community systems * has made an outstanding contribution to their state/community to connect medically and socially vulnerable populations to high quality healthcare services Please include: * how the individual or organization’s innovative approach to collaboration through the use of telehealth and/or other programs has been implemented to address clinical issues and patient needs, as well as provide support, resources, and education * how the individual or organization participated in the collaboration * how the initiative was identified as a need in the community * how the individual or organization demonstrated qualitative and/or quantitative outcomes that explain how the initiative is successfully addressing clinical issues and patient needs, as well as providing support, resources, and education to improve population health (if applicable) Paramedic This award recognizes an individual who: * is a non-administrative, certified paramedic whose primary job is direct patient care * has demonstrated exceptional qualities in one or more of the following areas: • quality assurance/improvement • patient care • medical control • disaster preparedness • public education and/or training * has acted “above and beyond the call of duty” in response to the EMS community and/or profession (please elaborate as to how the individual exceeded normal day-to-day job functions) Raymond H. Alexander – EMS Medical Direction This award recognizes an individual who: * is a licensed Florida physician * has assumed a leadership role in EMS within the community or state * has demonstrated excellence in the areas of quality assurance/improvement and medical control * has successfully promoted the use of new medical trends and technologies -------------------------------------------------------------------------------- NOMINEE INFORMATION -------------------------------------------------------------------------------- Select a Nomination Type* Select or enter value Caret IconCaret symbol First Name* Last Name* Organization Name* Organization County* Select Caret IconCaret symbol Address Line 1 Address Line 2 City Select Caret IconCaret symbol City - Other (not listed above)* State Zip Phone Phone Email -------------------------------------------------------------------------------- NOMINATION SUBMITTED BY -------------------------------------------------------------------------------- First Name* Last Name* Organization Name (if applicable) Address Line 1 Address Line 2 City Select Caret IconCaret symbol City - Other (not listed above)* State Zip Phone Phone Email -------------------------------------------------------------------------------- SUMMARY STATEMENT -------------------------------------------------------------------------------- Summary Statement* Prepare a summary statement describing how the nominee meets the award criteria, depicting the nominee’s qualities and contributions to EMS in Florida. Include why the nominee is exceptionally qualified and should be selected for this award. Break down the nomination criteria and describe in detail how the nominee has excelled in each area. -------------------------------------------------------------------------------- ATTACHMENTS -------------------------------------------------------------------------------- File Upload* Please attach the following for each submission: * Supporting Materials: Submit any materials to support the candidate’s nomination that you deem necessary, such as articles, letters, resumé, audio recordings, photographs, or additional documentation. * Electronic Photograph [required]: Submit an electronic photograph (high-resolution JPEG) of the nominee. This photo will be incorporated into the awards ceremony in the event the nominee is selected as a winner. * Signed Release Form(s) [required]: Submit the completed photo release form(s) signed by the individual or organization. Drag and drop files here or browse files -------------------------------------------------------------------------------- GUIDELINES -------------------------------------------------------------------------------- In order to be considered for an EMS Award: * A nominee cannot have any administrative actions pending with the Florida Department of Health. * All of the necessary information and supporting documentation must be provided. The deadline for the 2024 State EMS Award nominations is Sunday, June 30, 2024. -------------------------------------------------------------------------------- Send me a copy of my responses Submit Privacy Notice|Report Abuse