Vice-Chancellor’s Awards for Outstanding Community Engagement

Nomination Form 2017

Please complete

Section A: Individual Nominee DetailsName Position School/Division/

SectionInternal Bag Number

Nominee’s Signature

OR:Section B: Team Nominee Details

Team Name

Team Member’s Name

Position School/Division/Section

Internal Bag Number

Team Member’s Signature

Section C: Nominator DetailsName Position School/Division/

SectionInternal Bag Number

Nominator’s Signature

Section D: A 200-word summary description of the community engagement activity or activities of the nominee(s) and of the outcomes achieved.

This section may be prepared by either the nominator or the nominee.

Section E: Description of Activity/Project, Achievements and OutcomesA description of the community engagement activity or activities of the nominee(s), with statements that clearly identify the contribution of the nominee(s) (as compared with any non-nominee or external partners involved in the activity), the achievements and the outcomes, and the likely impact, durability and/or sustainability of those outcomes.

NOTE: Section E must not exceed two (2) A4 pages, font size 11pt.

This section may be prepared by either the nominator or the nominee.

Section F: Nominator’s Statement of SupportNominators are required to attach a brief statement of support against the following:

Extent to which the activity is outside the nominee’s job role at UTAS Extent to which the activity enhances the reputation of UTAS Extent to which the nominee has played a leadership role in the engagement activity Outcomes and impact of the engagement activity

NOTE: this attachment must not exceed two (2) A4 pages, font size 11pt.

Section G: External SupportNominations must include relevant brief statements of external support including letters, testimonials etc.

NOTE: this attachment must not exceed 10 pages. Media clippings can also be provided, via hyperlinks rather than printed articles.

Checklist for Nominators CompletedSection A – Individual Nominee Details (if applicable)Section B – Team Nominee Details (if applicable)Section C – Nominator DetailsSection D – 200-Word Summary DescriptionSection E – Description of Activity/Project, Achievements and Outcomes (must NOT exceed

two (2) A4 pages, font size 11pt) Section F – Nominator’s Statement of Support (must NOT exceed 2 A4 pages, font 11pt)Section G – Statements of External Support (must NOT exceed 10 pages)

Nomination SubmissionNominations should be forwarded in PDF Format, by Friday 2rd June, 2017 to Karen Edwards at Karen.Edwards@utas.edu.au.