Employee Awards and Recognition

Awards & Recognition Nomination Form
Nominee(s) Name*
NOTE: List multiple individuals on the same nomination if the service or action was generally performed together to approximately the same level. Consider submitting a separate nomination for individual(s) that performed at a notably different level.
Nominee Category*
Submitted By*

First NameLast Name
E-mail*
Phone Number*

Area CodePhone Number
Are you comfortable speaking on behalf of your nominee in the next Awards and Recognition Ceremony?*

Service: Task, project, accomplishment, duty, etc.
Describe the details of the service performed and the nominee’s role*
Explain the time frame or date range across which the service was performed *
Describe the nominee’s contributions (intellect, materials, time, etc.)*
Explain the nominee’s role/participation in relation to other people working on the project *
Describe the impact that the service had and for whom (department, members, fire service, City, community, etc.) *
Additional comments

Action: Single event, incident response, etc.
Date of Occurrence*

MonthDayYear
Time of Occurrence*

:HourMinutesAM/PM Option
Incident Details as Appropriate (Incident number, address, units involved, incident commander, etc.) *
Explain the situation leading up to the nominee’s actions (describe the incident, etc.) *
Describe the details of the nominee’s actions *
Explain what specific hazards or challenges the nominee faced *
Describe the result/outcome of the nominee’s actions *
Additional comments

Purple Cross: Injury or Death in the Line of Duty
Date of Occurrence *

MonthDayYear
Incident Details as Appropriate (Incident number, address, units involved, command, etc.) *
Explain the situation leading up to the occurrence *
Describe what occurred *
Additional Comments

Service: Task, project, accomplishment, etc.
Describe the details of the service performed and the nominee’s role *
Explain the time frame or date range across which the service was performed *
Describe the nominee’s contributions (intellect, materials, time, etc.) *
Explain the nominee’s role/participation in relation to other people working on the project *
Describe the impact that the service had and for whom (department, members, fire service, City, community, etc.)*
Additional comments

Action: Single event, incident response, etc.
Date of Occurrence*

MonthDayYear
Time of Occurrence*

:HourMinutesAM/PM Option
Incident Details as Appropriate (Incident number, address, units involved, incident commander, etc.)*
Explain the situation leading up to the nominee’s actions *
Describe how the nominee became involved and the details their actions *
Explain what specific hazards or challenges the nominee faced *
Describe the result/outcome of the nominee’s actions*
Additional comments

Awards & Recognition Nomination Form