2019 Palliative Care Awards Application Form
Palliative Care Australia’s 2019 Palliative Care Awards are aimed at recognising innovation, teamwork and emerging talent in the palliative care sector. The awards reward the efforts of those who support and care for people who are dying through public recognition of organisations and individuals who provide support and care to those people.

Award Applications Close Wednesday 10 July 2019

* These awards are exclusive to members of Palliative Care Organisations. Please refer to Awards Framework for more details.

Email address *
Your Contact Details
Please enter your details, of whom will be nominating the applicant for the awards
Your Name *
Your answer
Your Organisation *
Your answer
Please select the category below *
Required
Please select the award category *
Contact Details (for the individual nominee or team lead)
Title *
Your answer
Full name *
Your answer
Position title *
Your answer
Organisations *
Your answer
City *
Your answer
Email address *
Your answer
Business Hours Phone or Mobile *
Your answer
Date the nominee has commenced work in this position *
Your answer
Has the nominee consented to this nomination *
Required
Please select the Palliative Care organisation the nominee or their organisation is a current member of *
About the nomination
Why should this nominee or team/organisation be considered for this award.
Please address each of the criteria for the award category within the Awards Framework. *
Please note this is limited to 500 words. Judges will refer to this field to assess the finalists and winners.
Your answer
Previous Engagement with the National Palliative Care Awards
If the nominee or the lead in a team nomination has previously received an Award, please indicate the type of award, the year in which it was received and how it differs from this nomination *
Your answer
Privacy Notice
Palliative Care Australia (PCA) will always take reasonable steps to ensure your personal information is handled in accordance Australian Privacy Principles (APPs) contained in the Privacy Act 1988 (Cth) (Privacy Act) when handling all personal information provided for nomination purposes. For information about the PCA’s privacy policy, please go to https://palliativecare.org.au/about-pca-main-menu/palliative-care-australia-privacy-policy/.

Personal Information we may collect
As part of the nomination process PCA collects the personal information identified on this form. Where the nomination is on behalf of another person, the information above is collected about that person. If this information is not collected, the application will not be assessed. Please notify the PCA by email pca@palliativecare.org.au if the contact information required in this form changes.

How We Use Personal Information
Personal information is collected to assess eligibility for an Award, and to undertake statistical analysis in relation to the Awards program. PCA may also use this information to maintain an ongoing relationship with nominees, award prizes and invite nominees to relevant events and programs.

Privacy Consent
By nominating for an Award or providing information in support of a nominee’s application, you acknowledge and consent to PCA disclosing your personal information to the following persons and organisations:
• the nominee’s institution
• PCA’s board
• persons assessing the nominations
• event and program contractors performing services on behalf of PCA.

PCA may also publish successful nominees’ information (excluding details) in media releases, presentations, conference programs, booklets about the Award recipients and on the Oceanic Palliative Care Conference 2019 website and the PCA’s website.

PCA will not use or disclose personal information for any other purpose unless permitted by the Privacy Act 1988.

Consent *
Required
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