fDivers Alert Network

DAN Provider Award Program
Program Overview : Nomination Form

Please complete the following form to nominate an individual for an DAN Provider Award.

Note: DAN Training will only use the information provided on this form in the administration of Provider Awards. DAN will not solicit these people based on the your submission.


Nominator Information
Name:
Street Address:
City:
State:
Zip:
Country:
Daytime Phone:
Fax:
Email:

Nominee Information
I am nominating myself (skip this section)
Name:
Street Address:
City:
State:
Zip:
Country:
Daytime Phone:
Fax:
Email:

Location of Incident:
City/Town:
State/Province:
Country:

Incident Detail:
Date of Incident:
Time of Incident:
DAN Branded Equipment Used:
(Check all that apply)
Rescue Pak
Rescue Pak Extended Care
Dual Extended Care Rescue Pak
Soft Sided Rescue Pack Extended Care
First Aid Kit
First Aid Back Pack with O2
Pocket Mask
DAN Course(s) Used:
(Check all that apply)
Emergency Oxygen for Scuba Diving Injuries
Basic Life Support: CPR and First Aid
Neurological Assessment
First Aid for Hazardous Marine Life Injuries
Diving Emergency Management Provider
CPR HCP With First Aid
Diving First Aid for the Professional Diver
Diving Medical Technician

Description of Incident:
Please provide a complete description of the incident, including the actions of the rescuers, the equipment used and the incident outcome in as much detail as you can provide.
By checking this box, you agree that the information provided is, to the best of your knowledge, an accurate description of the incident.