Jeannie Ferris Cancer Australia Recognition Award

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2018 Nomination FormAward category descriptionsThe Jeannie Ferris Cancer Australia Recognition Award recognises individuals who have made outstanding contributions to improving outcomes for women with gynaecological cancers in two categories:

Category 1: Members of the communityThose with personal experience of gynaecological cancer, as a woman with a diagnosis of gynaecological cancer; a community or family member; or carers who have been directly involved in the support and care of a woman with gynaecological cancer.

Category 2: Health professionals or researchersResearchers and health professionals of all disciplines involved in gynaecological cancer research or clinical care, including (but not limited to) specialists, primary care practitioners, nursing and allied health professionals.

Tell us about the person you are nominating for the award

Title (Mr, Mrs, Ms. Dr, Prof, etc.)

Surname Given Name(s)

Postal address

Postal code State

Profession

Position/ Title

Organisation/ Business Name

Mobile Phone number Business Phone Number

Email Address

Nomination Category. Please tick only one. Members of the community Health professionals or researchers

This form is a fillable PDF. Please click on each field to enter text. Where indicated, there is a word limit for that particular field.

Compulsory eligibility criteria:

1. The nominee must be an Australian resident.

2. The nomination must include a short biography of the nominee (of no more than 500 words).

3. The nominee must give permission for the biographical details provided in the nomination to be used by

Cancer Australia in any promotional material, should they be selected as an Awardee.

4. The nomination must include two written references that support the nominee’s application.

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Please provide a short biography of the nominee – of no more than 500 words.

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Selection criteria

Applications must demonstrate how the nominee meets the following three selection criteria.

1. How has the nominee’s work or service improved outcomes for women with gynaecological cancers? Please provide specific examples. Max. 500 word limit.

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Selection criteria cont’d

2. How has the nominee’s contribution to women with gynaecological cancer impacted a particular field, community or group? I.e. has their contribution made a local, national and/or international impact? Please provide examples. Max. 500 word limit.

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Selection criteria cont’d

3. What makes this person’s contribution outstanding? Please provide examples (note: this may include contributions outside their paid work or position). Include any previous awards and relevant committee memberships. Max. 500 word limit.

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The Nominator

Please provide the following details about yourself.

Title (Mr, Mrs, Ms. Dr, Prof, etc.)

Surname Given Name(s)

Position/ Title

Organisation/ Business Name

Mobile Phone number

Email Address

Nominee Eligibility Checklist

1. Is the nominee an Australian resident?

Yes No

2. Have you included a short biography of the nominee (of no more than 500 words)?

Yes No

3. Has the nominee provided consent for the biographical details provided in his/her nomination to be used by Cancer Australia in any promotional material, should they be selected as an Awardee?

Yes No

4. Have you included two written references from referees outside of the nominee’s immediate family that support the nominee’s application, in the next section?

Yes No

This form is a fillable PDF. Please click on each field to enter text. Where indicated, there is a word limit for that particular field.

The next section requires some details about you as the nominator and also details and information from two referees.

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Referee OnePlease provide the following details about the referee.

Title (Mr, Mrs, Ms. Dr, Prof, etc.)

Surname Given Name(s)

Position/ Title

Organisation/ Business Name

Mobile Phone number

Email Address

Please provide a response to the following question.

1. What makes this person’s contribution to improving outcome for women with gynaecological cancers outstanding? Please provide specific examples. Max. 500 word limit.

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Referee TwoPlease provide the following details about the referee.

Title (Mr, Mrs, Ms. Dr, Prof, etc.)

Surname Given Name(s)

Position/ Title

Organisation/ Business Name

Mobile Phone number

Email Address

Please provide a response to the following question.

1. What makes this person’s contribution to improving outcome for women with gynaecological cancers outstanding? Please provide specific examples. Max. 500 word limit.

canceraustralia.gov.au

Important Notes

As a condition of nomination, each nominee MUST be an Australian resident and give permission for the biographical details provided in his/her nomination to be used by Cancer Australia in any promotional material, should they be selected as an Awardee. Please refer to the Frequently Asked Questions for suggested wording.

LODGING A NOMINATION Nominations may be made by any individual using the Nomination Form. Each nomination should address the selection criteria. Self-nominations are permitted. All nominations must be accompanied by references from two independent referees.

Nominations are to be sent to Cancer Australia:

By email (Word document attachment) to:

felicity.hughes@canceraustralia.gov.au

OR

By post addressed to:

Jeannie Ferris Cancer Australia Recognition Award

Cancer Australia

Reply Paid 86043

Locked Bag 3

STRAWBERRY HILLS NSW 2012

Nominations must be received by COB 8 March, 2018. Late applications will not be considered.

Nominations will be reviewed by a Selection Committee which will provide a recommendation to the CEO and Cancer Australia Advisory Council.

The Awards will be announced in June, 2018. Information about the successful Award recipients will be posted on the Cancer Australia website in June, 2018.

Thank you