Give full details of the person you are nominating:
Surname
First Names
Age
Occupation
Home Address
Have you informed the nominee/s that you have nominated them?
--
Yes
No
If they have been informed have they consented to you providing their personal data?
--
Yes
No
Please provide details of the witnesses
Were you a witness to the rescue?
--
Yes
No
Did anyone else assist in the rescue**?
--
Yes
No
If yes, give their name. If more than two people were involved, please fill in their details too (Full Names, Adresses).
Please provide details of the person saved (if known)
Surname
First Names
Age
Home Address
Did the person(s) rescued survive?
--
Yes
No
Give as full a description as you can of the rescue or attempted rescue and comment on the degree of danger
Where did the incident happen?
When did the incident happen?
What time of day was it?
What were the weather conditions?
Were the emergency services called?
--
Yes
No
If yes, which service(s)?
Did the rescuer give any form of resuscitation?
What form of resuscitation did the rescuer give?
Does the nominee have any training in First Aid, give details if known?
RESCUE FROM FIRE
Describe the fire (building, flames, smoke, internal, external, vehicle).
RESCUE FROM WATER OR ICE
Was the rescue from water or ice?
--
Yes
No
How deep was the water where the rescue took place?
If the rescuer had to swim, how far (there and back)?
Describe the water conditions (height of waves, strength of current)?
GENERAL (OTHER) RESCUE
Describe the rescue.
Other Information
Have you recommended the nominee for any other award?
--
Yes
No
If yes, please state to which organisation.
Name
Address
Email
Telephone
Send
