Barbara Chester Award: For Clinicians & Practitioners Working with Survivors of Torture
NOMINATION FORM

INSTRUCTIONS FOR USING THIS FORM

All received nominations will go through an initial review by the Selection Committee. At this stage, please provide only the information that has been requested. Do not attach supplemental materials, such as published articles.

After initial review, final candidates will be selected. At that point more information may be requested, and phone interviews will be scheduled with the ‘short-listed’ candidates.

Requirements.

1. Nominations must be submitted online using this form. Please be sure to click the "Submit" button at the end of the form [Note: Should technical difficulties arise, printed copies can be mailed or scanned and emailed.]

2. Required Information. Please fill-in all of the information in the text boxes provided on this form, with the exception for those items cited as "optional."

3. Resume. Please attach the nominee's resume in the listed section. The resume must be limited in size to know no more than 3,000 words or approximately 12 pages. Previous employment history should be included on the resume.

4. Narrative Answers. Several questions require a narrative response. Each question has a word or page limit. [Reminder:There are about 250 words on a page.]

Acknowledgement of Receipt. When you have completed the form and clicked on the "submit" button, you will be shown a copy of the information we received from you, acknowledging that the nomination was received on the website. If you did no receive this acknowledgement, please contact us as soon as possible.

--- If English is not your first language, please contact us at least 15 days prior to deadline.

Email address *
Nominee Information
Nominee - name of the candidate ( the person recommended to receive the Award.)

Enter the Nominee’s information here, and enter your own information further down below, under the section: "Nominator Information."

Prefix (Dr., Ms., Mr.) *
First Name *
Your answer
Middle Initial
Your answer
Last Name *
Your answer
Suffix ( Jr., Sr., ect.)
Your answer
Title *
Your answer
Organization *
Your answer
Email *
Your answer
Physical Mailing Address *
Your answer
City *
Your answer
State/ Province *
Your answer
Zipcode/ Postal Code *
Your answer
Country *
Your answer
Work Phone *
Your answer
Work Fax
Your answer
Home Phone
(Optional)
Your answer
Mobile Phone
(Optional)
Your answer
Website
(Optional)
Your answer
Date of Birth *
Your answer
Gender *
Required
Education Level *
If Other, specify degree information.
Required
Nominee Resume
The resume should be limited in size to no more than 3,000 words or approximately 12 pages.

Previous employment history should be included on the resume.

EMAIL the Nominee's Resume separately to:

bcaward@hopifoundation.org

Security & Confidentiality Requirements
REQUIRED - Please advise us if there are any security or confidentiality concerns that may require special attention to avoid endangering anyone or their work. If there are no concerns, check the box marked “NONE”. PLEASE DO NOT LEAVE THIS AREA BLANK -- either check the box marked “NONE” or explain the security and confidentiality concerns you may have. *
Required
If “Yes”, describe confidentiality or security concerns here:
(Maximum length: 125 words)
Your answer
Nominator Information
Nominator -- the person making the recommendation; the person filling out this form.
Nominator's Prefix *
Nominator's First Name *
Your answer
Nominator's Last Name *
Your answer
Nominator's Title *
Your answer
Nominator's Organization *
Your answer
Nominator's Day Time Phone *
Your answer
Nominator's Email *
Your answer
Is the nominee aware he or she is being nominated for the Barbara Chester Award? *
Required
Explain when and how you came to know the nominee, and the extent of your familiarity with your nominee’s work. *
(Maximum length: 750 words)
Your answer
About the Nominee: Scope of the Work and Issues Addressed
Select the major/primary area(s) of the nominee's focus of work. *
Required
What year did the work for which she/he is being nominated begin? *
(Indicate an exact year)
Your answer
The Narrative Story
Tell us the nominee's story. Please answer the following within the story to the best of your ability:
• What is the work that the nominee is doing?
• What population(s), communities does she/he work with?
• What is it about this work that is inspiring?
• What is it about the work that is exceptional, innovative, and/or unique?
• What are the nominee’s greatest accomplishments?
Use the following space to provide the answer to the above question(s): *
(Maximum length: 1,000 words or approximately 4 pages)
Your answer
Describe the nominee’s clinical approach with torture survivors. What percentage of the nominee’s time has been given to direct clinical service? Are there any specific social-cultural factors considered in performing the work? If so, describe these. *
(Maximum length: 500 words)
Your answer
Impact
What impact has the nominee’s work had on individuals, communities, the region, and/or the world? *
(Maximum length: 500 words)
Your answer
Degree of Risk
Is the nominee at-risk in carrying out his or her work? Please describe. *
(Maximum length: 250 words)
Your answer
Other Information
Is there any other information that you would like to include that would help to describe the nominee’s special qualities, contributions?
(Maximum length: 250 words)
Your answer
Nominee’s Fluency in English
Please indicate the Nominee’s fluency in English by checking a box, below. *
Required
References
Please provide the contact information below for one or more references that would support the nominee for recognition with the Barbara Chester Award.
Reference 1
Reference 1: Prefix
Reference 1: First Name *
Your answer
Reference 1: Last Name *
Your answer
Reference 1: Suffix (Sr., Jr., etc.)
Your answer
Reference 1: Title
Your answer
Reference 1: Organization
Your answer
Reference 1: Email *
Your answer
Reference 1: Phone (Daytime) *
Your answer
Reference 2
Reference 2: Prefix
Reference 2: First Name *
Your answer
Reference 2: Last Name *
Your answer
Reference 2: Suffix (Sr., Jr., etc.)
Your answer
Reference 2: Title
Your answer
Reference 2: Organization
Your answer
Reference 2: Email *
Your answer
Reference 2: Phone (Daytime) *
Your answer
Reference 3
(Optional)
Reference 3: Prefix
Reference 3: First Name
Your answer
Reference 3: Last Name
Your answer
Reference 3: Suffix (Sr., Jr., etc.)
Your answer
Reference 3: Title
Your answer
Reference 3: Organization
Your answer
Reference 3: Email
Your answer
Reference 3: Phone (Daytime)
Your answer
Please finish this form by clicking the "Submit" button below. Thank You!
A copy of your responses will be emailed to the address you provided.
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