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Award nomination form

Use this form to submit your award nomination for the PSA Symbion Excellence awards and MIMS Intern Pharmacist of the year award.

To be eligible to receive a national award, a nominee must be a PSA member, and have exemplified a contribution to the profession that aligns with one of PSA’s 11 Action Items For Change.

Nominations close Thursday July 16

Page 1

Nominee Details

I am nominating

MyselfSomeone else

Nominee first name

Nominee last name

Title

Post Nominals

Address line 1

Address line 2

Suburb

State

Post code

Nominee email address

Nominee phone (m)

Nominee phone (h)

PSA Branch (nominee must be a PSA member)

Nominated by

First name

Last name

Address line 1

Address line 2

Suburb

State

Post code

Phone (m)

Phone (h)

Organisation

Is the nominee aware of this nomination?

YesNo

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Award details

Is this a nomination for Intern of the Year?

YesNo

Intern Award details

What are the intern’s academic qualifications? (include Degree, University, year graduated)

What is the interns training period?

Please provide the contact details of up to two referees who support this nomination

Referee 1 - First Name

Referee 1 - Last Name

Referee 1 - Email address

Referee 1 - Phone (m)

Referee 1 - Phone (w)

Referee 1 - relationship to nominee

Referee 2 - First Name

Referee 2 - Last Name

Referee 2 - Email address

Referee 2 - Phone (m)

Referee 2 - Phone (w)

Referee 2 - relationship to nominee

Please provide examples of the intern’s leadership in pharmacy

Please provide examples of the intern’s peer and professional engagement

Please upload any supporting documentation such as CV, supporting statements from referees, etc.

doc, docx or PDF format

Award details (cont)

Which Award category are you nominating for? You may select more than one.

(CTRL click to select multiple awards)

PSA National Excellence Awards

PSA State Awards

NSW State Awards

VIC State Awards

QLD State Awards

SA/NT State Awards

WA State Awards

TAS State Awards

Nomination Details

To be eligible for an award, the pharmacist must contribute to the 11 Actions for Change as outlined in Pharmacists in 2023. Which one does the pharmacist contribute to? (More than one can be selected. CTRL+click to select multiple responses)

Please provide a citation (max 50 words)

Please detail the specific activities that display the 11 actions for Change in Practice (max 250 words)

Please list the qualities that make the nominee stand out in their field

(Maximum 250 words)

Please attach any supporting documentation (curriculum vitae, etc.)

Contact Information

CPD

Career & Support

Our Intern Training Program is open for enrolments

Networking & Events

Practice & Business Support

Advocacy

Media & Publications

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Award nomination form

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