4th Annual Public Safety Awards
NOMINATION FORM— Submission Deadline 4/24/20
Instructions: In order to properly evaluate this request, please complete this form (front and back) and provide
a detailed account of the incident/performance and why you believe it’s deserving of the award or acknowledgement, if
you feel necessary. Attach any paperwork related to the incident/performance that supports your request. Category
winners will be selected by the Washington County Chamber of Commerce Public Safety Awards Review Committee.
Return nomination forms to Donna Mitchell: [email protected]
The award breakfast is scheduled for Thursday, June 11th, 2020
Submitted by: __________________________________________________________________________________
Dept.: ________________________________________________________________________________________
Nominee: _____________________________________________________________________________________
Dept.: ________________________________________________________________________________________
Current Assignment: ____________________________________________________________________________
Select the Category that Fits the Organization of the Nominee:
FIRE/RESCUE: Fire, EMS, DES
LAW ENFORCEMENT: MSP, HPD, Sheriff, Hancock, Boonsboro, Smithsburg.
CORRECTIONS: All three correctional facility locations.
PUBLIC HEALTH: ER, Health Department, Urgent Care.
INCLUDE WITH THIS APPLICATION
Detailed description of incident
Supervisor’s comments, if necessary
May submit additional documentation (i.e. photos, letters, etc.)
Supervisor’s Signature: ______________________________________________ Date: ____________________
UNIT ACHIEVEMENT AWARD (1 Winner from Each Category):
This honor is awarded to any bureau, division, section, unit, or squad exhibiting extraordinary performance,
attention to duty, and for an outstanding contribution to the department or to the welfare of our citizens.
PUBLIC SAFETY DISTINGUISHED SERVICE AWARD (1 Winner from Each Category):
This award is presented to a responder who is distinguished from all others of their rank or position. He or she
performs above expectation, demonstrates responsibility, and initiated a credible accomplishment in the previous year.
COMMUNITY SERVICE AWARD (Only 1 Person or Group is Able to Receive This Award Regardless of Category):
This award is presented to an individual, group or organization who has worked to better the lives of those in
Washington County, either inside or outside of normal job duties, or has performed a single outstanding
community service activity. Examples include: Education, mass education courses, crime reduction, self-defense, prevention.
Programs like “Coats for Kids”, etc.
LIFETIME ACHIEVEMENT AWARD (Only 1 Person of Group is Able to Receive This Award Regardless of Category):
The individual awarded this honor encompasses leadership and an exceptional work ethic. He or she has
consistently performed above & beyond normal expectation throughout their career.
MEDAL(s) OF VALOR AWARD
Gold: This award recognizes an act of bravery involving extreme personal risk that is clearly above and beyond the call of
duty or an incident of valor that results in serious injury or death.
Silver: This award recognizes acts of bravery involving great personal risk beyond the call of duty.
Bronze: This award recognizes acts of bravery involving unusual personal risk beyond expectation while performing
the usual responsibility. Bronze-level recognition may also be awarded to a member who demonstrates unusual judgement,
zeal, or ingenuity during an emergency situation when such an act is beyond that normally expected in the line of duty.
TELECOMMUNICATION AWARD (Telecommunications Category Only):
This individual, through their outstanding dedication and service has demonstrated an exceptional contribution to the improved
delivery of emergency medical, fire and law enforcement services to the citizens and visitors of Washington County.
VOLUNTEER ACHIEVEMENT AWARD (1 Winner from Each Category):
This honor is presented for volunteer dedication and initiative above and beyond the call of duty over a period of time that has
affected and benefited the citizens of Washington County and beyond.
GOOD SAMARITAN AWARD:
This award recognizes a non-uniformed, untrained citizen who clearly goes above and beyond, performing an act of selfless-
ness and bravery during an emergency situation.
HERO AWARD:
This award honors an individual or team whose actions attempted to save or succeeded in saving a human life. Recipients
demonstrate strong knowledge of medical and rescue efforts, quick action, and a commitment to service on and off duty.
Description of Awards
Please Select the Award You’re Submitting for: