ACEM Foundation Al Spilman Award for Cultural Safety Initiatives in an Emergency Department

ACEM Foundation Al Spilman Award for Cultural Safety Initiatives in an Emergency Department
Form No: AP613
Last Revised: June 2025
Version: V4

Complete this nomination form for the ACEM Foundation Al Spilman Award for Cultural Safety Initiatives in an Emergency Department within the advertised timeframe.

Refer to Al Spilman Award for Cultural Safety Initiatives in an Emergency Department FND612 v5 for eligibility and selection criteria.

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

The nominator must be an ACEM member or a trainee, who is of good standing with the College (please refer to Policy FND612 v5 for further detail).
Nominator name*

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

Clear
Date*

DayMonthYear
Date
I am a*

ACEM member of good standing with the CollegeACEM trainee of good standing with the College
Nominee

The award is open to an ACEM accredited emergency department from either Australia or Aotearoa New Zealand.
Name of initiative*
Nominated emergency department*
Please provide a brief summary of the initiative*
Selection Criteria
Describe how the initiative demonstrates collaboration with Aboriginal and Torres Strait Islander, or Māori peoples within the health service or community.*
Describe how the initiative demonstrates culturally safe practice that focuses on the experience of Aboriginal and Torres Strait Islander or Māori patients and carers receiving emergency care.*
Describe how the initiative demonstrates culturally safe practice that focuses on the experience of Aboriginal and Torres Strait Islander, or Māori staff in the emergency department.*
Describe how the initiative demonstrates sustainability.*
Describe how the initiative demonstrates capacity building.*
Describe how the impact of your initiative is measured.*
Declaration
I have read the conditions associated with the ACEM Foundation Al Spilman Award for Cultural Safety Initiatives in an Emergency Department within the policy FND612 v5 and agree to comply with them as required.
Name*

First NameLast Name
Signature*

Clear
Date*

DayMonthYear
Date
Nominations will be reviewed by the Indigenous Health Committee and the ACEM Foundation Committee before submission to the ACEM Board.
Should be Empty:

ACEM Foundation Al Spilman Award for Cultural Safety Initiatives in an Emergency Department

Eligibility

Selection Criteria

Declaration