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Organization Name(Required)

Organization Contact(Required)

Position with Organization(Required)

Email(Required)

Phone(Required)

Describe the project and/or program that the organization has developed and implemented to address firefighter health and safety at the local, state or national level(Required)

Is this a new project/program, or did the organization model it after an existing program developed by another organization?(Required)

Did the organization develop partnerships with other organizations or government agencies to implement the program? If yes, please describe the partnership.(Required)

Provide outcomes and accomplishments of the program, specifically identifying which of the 16 Firefighter Life Safety Initiatives were addressed.(Required)

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Name of Individual Submitting Application(Required)

Submitter's Email Address(Required)

Submitter's Phone Number(Required)

Name of Candidate for Award(Required)

Upload Supporting Documents

Please upload a formal nomination letter not exceeding 1,000 words and letters of support. Microsoft Word Documents, PDF, JPG and PNG files only. Large documents should be emailed to [email protected] with "Mason: Your Candidate's Name" in the subject line.

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Phone

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Nominator Information

Name(Required)

Position(Required)

Phone(Required)

Email(Required)

Nominee Information

Name(Required)

Position(Required)

Phone(Required)

Email(Required)

Describe the nominee’s fire and life safety education contributions(Required)

During the course of her/his professional career, has the nominee developed any innovative fire and life safety education programs? If so, please describe(Required)

Are these programs national in scope? If so, please explain their impact on public safety education.(Required)

Describe how the nominee has served as a catalyst for fire and life safety education.(Required)

Comments

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Name of Fire Department(Required)

Type of Department(Required)

Fire Department Contact(Required)

Position with Department(Required)

Email(Required)

Phone(Required)

Explain what prompted the fire department to develop the practice and whether it was an issue for one department or other fire departments as well. Also, indicate if the practice impacted EMS at the local, state, and/or national levels.(Required)

Is this a new project/program or did your fire department model it after an existing program developed by another fire department or organization?(Required)

Did the fire department develop partnerships with other organizations or government agencies (e.g., hospitals, the private sector, law enforcement, research centers, learning institutions, or other fire departments) to implement the program? If so, please describe the partnerships.(Required)

Provide demonstrated outcomes/accomplishments attributed to the new program or innovation.(Required)

Will this program be ongoing or will it be active during a specific time frame?(Required)

This field is for validation purposes and should be left unchanged.

Congressional Fire Services Institute

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Nominator Information

Nominee Information

Congressional Fire Services Institute

Educating Members of Congress About Fire & Life Safety Issues Since 1989

Call for Seminar Proposals

Submit Your Proposal Today!

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