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Medal of Valor Nomination Review
Agency Head Approval
Nominator Information
Nominator Name
Nominator Name
Nominator Email Address
Nominator Email Address
Nominator Title
Nominator Title
Nominator Phone Number
Nominator Phone Number
Nomination Information
Nomination Type
Nomination Type:
Individual or Team
Nominee Name
Nominee Name
Nominee Employer
Nominee Employer
Nominee's Relationship to Facility where the incident occurred
Nominee's Relationship
Nominee Rank / Title
Nominee Rank
Nominee Years of Service
Nominee Years of Service
Additional Team Members
Incident Information
Incident Date
Incident Date
Facility / Institution Name
Facility Name
Facility / Institution Address
Facility Address
Specific Incident Location
Incident Location
Incident Type
Incident Type
Act of Valor
Description of the qualifying incident and the actions of the nominee(s) for the nomination. The selection committee must be able to understand the danger involved, the personal risk assumed by the nominee(s), the actions taken, and how those actions protected or attempted to protect the life or safety of another person.
Circumstances of the Incident
Circumstances
Danger or Risk
Danger
Actions of the Nominee(s)
Action
Protection or Preservation of Life
Protection
Outcome
Outcome
Basis for the Medal of Valor
Basis
Endorsement Information
Facility Endorser Name
Endorser Name
Nomination Endorsed Date & Time
Date & Time of Endorsement
Endorser Title
Endorser Title
Agency Head Decision
Please review the nomination above before recording your decision. You may include optional comments below.
This agency-head approval link is invalid or incomplete.
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