ACEM Wellbeing Award

ACEM Wellbeing Award
Form No: AP652

Last Revised: March 2025

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 Wellbeing Award Policy.
Are you nominating an individual or group?*

IndividualGroup
Nominee (Individual)
To be eligible for the ACEM Wellbeing Award (individual), the nominee must be an individual member or trainee of the Australasian College for Emergency Medicine (ACEM), who is proactively putting in place strategies to encourage and promote physical and mental wellbeing of emergency department staff.
Name of nominee*

First NameLast Name
Contact number of nominee*
Please enter a valid phone number.
Email of nominee*
example@example.com
Role of nominee*
Nominee (Group)
To be eligible for the ACEM Wellbeing Award (Group / ED), the nominee must be either:
- an emergency department; or
- a group comprised of ACEM members, not necessarily from the same ED;
located in Australia or Aotearoa New Zealand, which is proactively putting in place strategies to encourage and promote physical and mental wellbeing of emergency department staff.
Name of emergency department or group:*

- 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 AP650 for further details).
- Nominator name*
  
  First NameLast Name
- Nominator email*
  example@example.com
- Nominator ACEM ID
- What position do you hold?*
- At what emergency department?*
- In what capacity are you familiar with the nominee?*
- Nominator signature*
  
  Clear
- Date*
  
  DayMonthYear
  Date
- Seconder details
  
  These details will be used to notify your seconder to complete their section of this form. The seconder must be an ACEM member or trainee enrolled in the FACEM Training Program who is of good standing with the College.
- Seconder name*
  
  First NameLast Name
- Seconder 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 and supporting wellbeing initiatives for emergency department staff. Additional pages may be attached if required.
- Selection criteria
  
  Nominations for the award will be assessed according to the extent to which the individual’s and/or group/ emergency department’s initiative demonstrates evidence of;
  
  Implementation
  
  Implementation within an organisation of an initiative(s) that aims to enhance EM staff physical and mental health and wellbeing, i.e. scheduling of activities, feedback from employees, newsletters/other communication announcing initiative components.
- Innovation
  
  The extent to which the initiative(s) is based on/incorporates a new approach to addressing the specific challenge identified that was targeted by the initiative(s).
- Sustainability
  
  Long term sustainability – in that there is a focus on systemic change within the health service, and outcomes of the initiative(s) are embedded in current and/or future organisational strategies.
- Outcomes
  
  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.
- Engagement
  
  Engagement and consultation with relevant emergency medicine staff during their development and implementation.
- Standards
  
  Alignment with the Australian and/or Aotearoa New Zealand standards/guides for medical practitioner health and wellbeing.
- Nominated individuals, groups or emergency departments will be invited by the College to submit a written or video citation addressing the Selection Criteria to further support the nomination, by such deadline specified by the College for this purpose.
- 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.*
  
  0/300
- Submission
- For further information about the award, refer to the ACEM Wellbeing Award Policy.
  
  Nominations for the 2025 ACEM Wellbeing Award must be received by the closing date.
- The seconder must be an ACEM member or trainee enrolled in the FACEM Training Program who is of good standing with the College.
- I am an ACEM member of good standing with the CollegeI am an ACEM trainee of good standing with the College
- Seconder name
  
  First NameLast Name
- Seconder ACEM ID
- Seconder signature
  
  Clear
- Date
  
  DayMonthYear
  Date
- Submission
- For further information about the award, refer to the ACEM Wellbeing Award Policy.
  
  Nominations for the 2025 ACEM Wellbeing Award must be received by the closing date.
- Should be Empty:

	Name	Phone number	Email
Contact 1
Contact 2
Contact 3

ACEM Wellbeing Award

Nominee (Individual)

Nominee (Group)

Seconder details

Supporting evidence

Selection criteria

Implementation

Innovation

Sustainability

Outcomes

Engagement

Standards

Summary

Submission

Submission