Individual Nomination Application Form

Please submit a cover page with the following information:
1. Nominators - include names, titles, organization, full address, telephone, fax and email.
2. Nominee - include organization, full address, telephone, fax and email.
3. Individual Awards Category - (select one)
  - Return to Work Coordinator / Disability Management Professional
  - Outstanding Public Leadership in Disability Management.
Outline the reasons for nominating this individual:
1. Describe your reasons why the nominee should be considered a strong candidate for a National Award of Excellence in Disability Management.
2. Describe the contributions the nominee has made in disability management that have benefited workers with disabilities, the workplace or other organizations.
Show evidence of this nominee's success -
Please provide objective evidence and/or outcome illustrations to support your nominee, as related to the following criteria indicated by your award category.
1. Return to Work Coordinator / Disability Management Professional
  - Disability Management Resourcefulness
    Describe the nominee's ability to identify, develop, coordinate and utilize disability management resources from the workplace and the community, in order to develop and implement effective disability management programs, services and interventions at the workplace.
  - Disability Management Influence and Support
    Describe the nominee's ability to successfully influence others to support joint disability management initiatives.
  - Disability Management Leadership
    Describe how the nominee has demonstrated disability management leadership among workers, supervisors, unions, managers, community leaders and others to promote return-to-work activities for workers with disabilities.
  - Disability Management Creativity
    Describe the nominee's creativity in designing proactive interventions, policies or other disability management initiatives, despite obstacles.
  - Disability Management Commitment
    Provide evidence of the nominee's personal and professional commitment to joint disability management principles and practices.
  - Disability Management Motivation
    Describe the nominee's ability to maintain self-motivation and to motivate others to support and strengthen disability management programs and services for workers with disabilities.
2. Outstanding Public Leadership in Disability Management
  - Disability Management Leadership
    Describe how the nominee has demonstrated substantial disability management leadership, affecting a broad range of workers and/or organizations, communities and society at large.