ACEM Equity and Inclusion Award

ACEM Equity and Inclusion Award
Form No: FND928
Last Revised: November 2024
Version: V1

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.
Are you nominating an individual or a group?*

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
Role of nominee*

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.
Role of nominee*

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 (DEMHuman Resources departments of health servicesInclusion CommitteeOther
Name of emergency department or group*

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).
Full name*

First NameLast Name
Email*
example@example.com
ACEM ID
Signature*

Clear
Date*

DayMonthYear
Date
What position do you hold?*

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?
Seconder
The seconder must be an ACEM member or trainee enrolled in an ACEM Training Program who is of good standing with the College.
Declaration*

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*

Clear
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. Additional pages and evidence in support of this may be attached if required.

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:*
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:*
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:*
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:*
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.*
Please upload any additional supporting documentation

Cancelof
Should be Empty:

	Name	Contact Number	Email
1
2
3

ACEM Equity and Inclusion Award

Nominee (Individual)

Nominee (Group)

Nominator

Seconder

Supporting evidence

Selection Criteria

Summary