Employee Name *

First Name

Last Name

Nominator *

First Name

Last Name

Date of Event *

MM

DD

YYYY

Nominee must meet one of the following criteria. A complete description of the event or action must be given. *

Accomplishment of a Noteworthy Deed: Demonstrating exceptional courtesy, responsiveness or assistance when interacting with the members of the public. Cite the specific noteworthy deed, how this went beyond regular job duties and reflected positively on the Public Safety Division.

Extraordinary Performance: An action that had a specific beginning and end and had an identifiable result or outcome. Cite specific examples of repeated excellence; describe how they went beyond regular job duties and how these actions reflected positively on the Public Safety Division.

Problem Resolution: Solved an extraordinary problem or achieved a significantly difficult goal. State the problem or goal, how it was solved or achieved, and describe the impact that this has had on the membership.

Innovation: Successfully implemented an innovative idea where outstanding results were identifiable. Describe the idea, the action taken to achieve it and the results, including cost savings, if known.

Acceptance of special assignments beyond the parameters of normal duties. Explicitly detail with specific examples how the actions went beyond the normal job duties.

Other actions deemed as notable by the supervisor and department head. In defining these notable actions, cite the specific action or actions, how these actions went beyond regular job duties and reflected positively on the Public Safety Division.