APSAD Mentor Award Nomination Form

APSAD Mentor Award Nomination Form

The Mentor Award recognises an individual who has made an important contribution to mentoring and supporting the career development of clinicians, researchers, or students.
Eligibility

Any individual with a track record of mentoring and supporting the career development of alcohol, tobacco and/or other drugs: clinicians, researchers and/or students.

Selection Criteria

Ability to demonstrate energy, passion and commitment for mentoring and demonstrate integration of your mentees into the wider alcohol, tobacco, and other drugs field and/or related fields (outside your own organisation), and/or provide evidence of how you have implemented and supported programs and policies for the broader development of mentoring across your organisation and/or discipline.

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 an important contribution and support on career development for mentees.
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 important contribution and support on career development for mentees - 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 testimonials and/or case examples, copy of relevant webpage promoting the program or outline of the course, workforce development/organisational learning initiatives designed to advance clinician expertise & good practice on the ground.
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 Mentor Award.

Clear
Confirmation from the nominator
NOMINEE'S CONFIRMATION*

I agree to be nominated for consideration for the APSAD Mentor 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