APSAD Clinician Award Nomination Form

APSAD Clinician Award Nomination Form

The Clinician Award recognises excellence and leadership in clinical practice, in the field of substance use in any discipline.
Eligibility

Any individual in a substantiative (50% or more) position providing direct delivery of clinical services or operating in a strategic managerial position directly relating to service provision.

Selection Criteria

Evidence of significant positive impact on outcomes for consumers and/or service provision in the sector. Nominees will need to show the extent of the impact of their work and how it has made a substantial and practical contribution to the service or sector. Information can include (but is not limited to): publications if applicable, evaluations, recognition from other groups and endorsements, list of initiatives and actions you have taken and the impact they have had.

NOMINATOR'S DETAILS

Details and contact information for the person who is nominating
Name*

PrefixFirst NameLast NameSuffix
Organisation*
Include the organisation of the nominator
Current Position*
What position does the nominator hold
Email*
Nominator's email address
Phone Number*

Country CodeArea Code (0 for mobile)Phone Number
Confirmation the Nominator is a current APSAD member*

Yes, I confirm my membership is current
NOMINEE'S DETAILS

Details and contact information for the person being nominated for this Award
Name*

PrefixFirst NameLast NameSuffix
Organisation*
Include the organisation of the nominee
Current Position*
What position does the nominee hold
Email*
Nominee's email address
Mobile Number*
nominee's mobile number.
Qualifications

Include qualifications for the person being nominated, including year obtained and where.
Qualification Qualification* . Year Year qualification was obtained* Where Institution qualification was obtained .
Qualification Qualification . Year Year qualification was obtained Where Institution qualification was obtained .
Qualification Qualification . Year Year qualification was obtained Where Institution qualification was obtained .
Qualification Qualification . Year Year qualification was obtained Where Institution qualification was obtained .

SELECTION CRITERIA

Applicants must provide evidence of a positive impact on outcomes for people with lived or living experience and/or service provision in alcohol, tobacco, and other drugs.
Upload the nominator's supporting statement and the nominee's contribution summary below, make sure you stick to the allocated word limits.
NOMINATOR*

Indicate the Nominee's positive impact on outcomes for people with lived experience and/or service provision in alcohol, tobacco, and other drugs - max 500 words.
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NOMINEE'S CONTRIBUTION SUMMARY*

Provide a brief summary - no more than 2,000 words - outlining your contribution as per the selection criteria to the alcohol, tobacco and other drugs field.
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SUPPORTING DOCUMENTATION

Upload your supporting documentation. Nominee’s CV; 3-5 prominent publications and/or examples involving program development & implementation that improve services for alcohol, tobacoo, and other drugs treatment clients. Show the extent of the impact and how it has made a substantial and practical contribution to the service or sector. (i.e., publications, evaluations, recognition from other groups and endorsements, list of initiatives & actions taken and their impact).
Supporting Documentation Upload*

Upload your supporting documentation
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Use the checks boxes below to ensure you have completed the form and uploaded all required information before submitting the form*

A brief statement indicating why you support the nomineeNominee's contribution summaryUploaded the nominee's CVSupporting documentation has been uploaded

DECLARATION

Both Nominator and Nominee are required to confirm the information provided in this form is accurate and true.
Nominator's Declaration:

To confirm your support for this nomination, you can;
- sign this form, or
- send an email confirming your nomination to awards@apsad.org.au
Nominator: As an APSAD member I submit this nomination for the APSAD Clinician Award.

Clear
Confirmation from the nominator
NOMINEE'S CONFIRMATION*

I agree to be nominated for consideration for the APSAD Clinician Award and confirm should I be successful will be attending the APSAD 2025 in Gadigal (Sydney) to receive the Award.
Nominee's Signature

Clear
confirmation from the nominee
Should be Empty:

Eligibility