ACEM Equity and Inclusion Award

ACEM Equity and Inclusion Award
Form No: F928
Last Revised: March 2026
Version: V2

Note: If you need assistance filling this form or would prefer to submit a written application, please contact honours@acem.org.au

For further information about the award, refer to the ACEM Equity and Inclusion Award Policy.
IndividualGroup
Nominee (Individual)
The award recognises those who are proactively putting in place a well thought through strategy that aims to establish and foster a more inclusive and equitable environment for staff, patients and community.
Name of Nominee*

First NameLast Name
Contact number of nominee*
Please include country code
Email of nominee*
example@example.com
Individual ACEM MemberNurse and/or allied health staffEqual opportunity officerOther
Nominee (Group)
To be eligible for the ACEM Equity and Inclusion Award (Group), the nominee must be located in Australia or Aotearoa New Zealand and has proactively put in place a well thought through strategy that aims to establish and foster a more equitable and inclusive environment for staff, patients and community.
A group comprised of ACEM members, not necessarily from the same EDAn emergency department located in Australia or Aotearoa New Zealand submitted under the signature of the Director of Emergency Medicine (DEM)Human Resources departments of health servicesInclusion CommitteeOther
Name of emergency department or group*
Please upload a short, signed statement from the DEM supporting the nomination.*

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- Nominator
- The nominator must be an ACEM member or a trainee, who is of good standing with the College, or a senior hospital administrator, other medical practitioner or senior nursing staff member employed in an ED (please refer to Policy AP722 for further details).
- Nominator full name*
  
  First NameLast Name
- Email*
  example@example.com
- ACEM ID
- Nominator signature*
- Date*
  
  DayMonthYear
  Date
- ACEM member of good standing with the CollegeACEM trainee of good standing with the CollegeSenior nurseOther medical practictionerSenior hospital administrator
- Emergency department you work in*
- In what capacity are you familiar with the nominee?*
- Provide details for seconder
- These details will be used to notify your seconder to complete their section of this form. The seconder must be an ACEM member or trainee enrolled in the FACEM Training Program who is of good standing with the College.
- Seconder name*
  
  First NameLast Name
- Seconder email*
  example@example.com
- I am an ACEM member or trainee enrolled in an ACEM Training Program who is of good standing with the College.
- Full name
  
  First NameLast Name
- ACEM ID
- Signature
- Date
  
  DayMonthYear
  Date
- The Nominator or the Seconder to provide contact details for a referee who can provide a brief written or verbal report on the practical application of the initiative.
- Referee name*
  
  First NameLast Name
- Referee email*
  example@example.com
- Supporting evidence
- Nominators are required to describe in as much detail as possible evidence of the nominee’s commitment to delivering, supporting and implementing equity and inclusion initiatives for emergency department staff and/or patients and/or the wider community.
  
  Selection Criteria
- Promotion of equity, inclusion, cultural competency and/or Cultural Safety development among emergency department staff via innovative equity and inclusion initiatives that establish and foster a more inclusive and equitable work environment and/or
  
  Development of innovative equity and inclusion initiatives or programs that establish and foster a more culturally safe, inclusive, and equitable environment for patients;
  
  For nominations relating to community activities outside the ED: providing support to community-based diversity and equity programs designed to improve people’s cultural awareness and sensitivity and/or promote greater inclusion for communities that have been largely excluded.
- Please explain how the nominee has demonstrated the above:*
  
  0/750
- Promotion of a diverse, equitable and inclusive culture by challenging inequalities, barriers and/or bias in the application of people management policies. For example, inclusive recruitment, performance management, career development and promotion etc, or customer service delivery;
  
  For nominations relating to community activities outside the ED: encouraging employee volunteerism in the community with regard to cultural connections.
- Please explain how the nominee has demonstrated the above:*
  
  0/500
- Long term sustainability – in that there is a focus on systemic change within the health service, and outcomes of the initiative(s) is/are embedded in current and/or future organisational strategies.
- Please explain how the nominee has demonstrated the above:*
  
  0/500
- Impact and outcomes – the extent to which the initiative(s) has addressed challenges, achieved the desired outcomes and/or positively impacted on the individual(s) and/or group(s) targeted by the initiative(s). Describe how the initiative was evaluated and how the impact is measured.
- Please explain how the nominee has demonstrated the above:*
  
  0/750
- The efforts and achievements must have been demonstrated through:
  - specific work with other individuals or groups, or
  - a specific product, initiative, innovative program or activity,
  that has a visible, tangible or measurable impact on the perception of, attitude toward and respect for a truly equitable and inclusive environment for all, in which the variety of cultures, experiences, expertise and viewpoints are valued and incorporated into the delivery of emergency medical care, and where individuals are valued for their talent and able to reach their full potential.
- Summary
- Please provide a written statement of no more than 300 words, summarising the information provided. If the nomination is successful, this statement will inform the presentation of the award at the designated ACEM event.*
  
  0/300
- Please upload any additional supporting documentation
  
  Cancelof
- Seconder
- The seconder must be an ACEM member or trainee enrolled in an ACEM Training Program who is of good standing with the College.
- I am an ACEM member or trainee enrolled in an ACEM Training Program who is of good standing with the College.
- Full name
  
  First NameLast Name
- ACEM ID
- Signature
- Date
  
  DayMonthYear
  Date
Should be Empty:

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ACEM Equity and Inclusion Award

Nominee (Individual)

Nominee (Group)

Nominator

Provide details for seconder

Supporting evidence

Selection Criteria

Summary

Seconder