Higgins and Langley Memorial Awards
in Swiftwater Rescue

Before filling out this form please carefully read the awards criteria. If you'd prefer to print out the form and send it in, you may download it in PDF format.

1. Nomination Year:

2. A nomination is submitted for the following category:
   Incident
   Special Commendation
   Program Development
   Outstanding Achievement
   Lifetime Achievement

3. Type of nominee:
   Individual
   Multiple Individuals
   Team
   Multiple Teams
   

4. Type of duty:
   Paid full-time Professional
   Paid part-time Professional
   Unpaid/Volunteer Professional
   Combination (individuals)
   Combination (teams)

5. Date/Period being recognized:
   1. Commence Date/Time:

   2. Conclusion Date/Time:

6. Name of Incident/Program:

7. Nominee or Primary POC: (additional nominees, parties, team members listed below as needed; all information shall be included for every listing)
   1. Name:
   2. Title:
   3. Unit/Duty Station:
   4. Address:
   5. City:
   6. Zip/Post Code:
   7. State/Province:
   8. Country:
   9. Phone (home):
   10. Phone (work):
   11. Phone (mobile):
   12. E-mail address:
   13. Highest level of swiftwater rescue training:

8. Summary of incident/events/program (brief description):

9. Describe all training, qualifications, certifications, capabilities and skills of the rescuer(s)/team(s) with emphasis on swiftwater and/or related specialty training.

10. Environmental Conditions: On scene weather, water state, rapids class, air/water temperature, date/time of incident incursion, date/time of incident conclusion, other details.

11. List of Attachments: (Check [and email as attachments] all credible supporting documentation)
    Complete/Detailed Summary of Incident
    Nominee statement
    Newspaper Articles
    Police/Fire/Rescue Reports
    Witness Accounts
    Video/Audio Reports/clips
    On-Scene Commander Report
    State/Provincial Agency Reports
    Copy of certification(s)
    Coroner's Report
    Federal Agency Reports
    Other Recognition (nominated or received)
    ICS Reports
    Affidavit(s)
    Other Attachment

12. Submitting Official/Chief/Commander:
    1. Name:
    2. Title:
    3. Signature:
    4. Date of Submission:
    5. Unit:
    6. E-mail address:
    7. Address:
    8. City:
    9. State/Province:
    10. Country:
    11. Zip/Post Code:
    12. Phone (work):
    13. Phone (mobile):

Please fill out a separate block for each nominee or team member. Unlisted nominees cannot be considered!

1. Nominee or Team Member:
   1. Name:
   2. Title:
   3. Unit/Duty Station:
   4. Address:
   5. City:
   6. Zip/Post Code:
   7. State/Province:
   8. Country:
   9. Phone (home):
   10. Phone (work):
   11. Phone (mobile):
   12. E-mail address:
   13. Highest level of swiftwater rescue training:
   
   add another nominee