BARBARA CHESTER AWARD 2006 Nomination Form INSTRUCTIONS: SPECIAL NOTE FOR PLAIN TEXT: This form was designed for Size 9 COURIER NEW font on a DOS-based PC. If the fields or field names do not properly align, please adjst your font and font size. 1. Type or print in dark ink. Add or attach extra pages as needed to fully escribe your nominee's merits. A resume or curriculum vitae and other documents may be attached, but attachments cannot be returned. 2. You may photocopy this form or request additional forms (see Contact information at the end of this form). You may download additional forms from the internet, or you may fill out and submit a form online (www.barbarachesteraward.org). 3. Definitions: - Nominee: the candidate; the person recommended to receive the Award. - Nominator: the person making the recommendation; the person filling out this form. 4. We appreciate the excellent work being done by clinicians and healing practitioners from a wide range of backgrounds around the world. Candidates are evaluated on the merits of their work and on their unique strengths -- not their educational, employment, or publications status. 5. If English is not your primary language, please note that we are interested in the quality of your candidate's work, not your writing skills. Please either use a translator or write your descriptions as simply and as clearly as you can. We regret that we cannot provide translation services at this time, but we encourage you to contact us with any questions or about any problems you are having, and we will try to help. I. THE NOMINEE I recommend the following person to receive the Barbara Chester Award: ______________________ ________________ ______________________________________ First Name Middle Name Last Name Gender: Male: ____ Female: ____ Date of Birth: ____________________________ Place of Birth: ________________________________________________________________ Nominee's Mailing Address: ________________________________________________________________________________ Street and Number ______________________ _____________________ __________ _______________ City State or Province Postal Code Country ________________ _________________ ______________________________________ Telephone Telefax e-Mail Address Nominee's Employment History ________________________________________________________________________________ Current Work or Job Title ________________________________________________________________________________ Current Employer or Organization Date of Current Employment: ____________________________ Past Employment Please list and Describe (Add pages or resumes as needed): ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Nominee's Completed Levels of Education and Training. Please check all that are appropriate: Grade School ____ High School ____ Partial College ____ Bachelor's or 4-Year Degree ____ Type of Degree: ________________ Major: ____________________ Graduate Degree(s) and Field(s) of Study ________________________________________________________________________________ ________________________________________________________________________________ Other Degree(s) or Training (or Internships/Apprentices) ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Publications by the Nominee (Please attach a resume or curriculum vitae, or list representative publications, if relevant.): ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Special Qualities and Accomplishments of the Nominee Please explain why you have nominated this person to receive the Barbara Chester Award. You may also wish to tell about your nominee in a factual narrative or story. In your explanation or narrative, it may be helpful to include information about the nominee's special and unique capabilities and accomplishments. Add pages or resumes as needed. The following are examples of information you may wish to include - Client population(s) the nominee has worked with - Community settings where s/he has worked - Length of time s/he has worked treating the survivors of torture - Nature of the relationship between the nominee and the clients/community s/he serves - Examples of advocacy for clients and human rights - Excellence of clinical skills and qualities - Indications of resourcefulness and commitment - High risk nature of the setting in which the nominee is working - Case illustrations. Examples of how the nominee worked with specific clients and the outcome. Please do not disclose the clients' real names ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ II. THE NOMINATOR Nominated by: ______________________ ________________ ______________________________________ First Name Middle Name Last Name What is your Professional Title or Institutional Affiliation? ________________________________________________________________________________ Please provide a mailing address, telephone, and telefax number(s), and an e- Mail address where we may contact you. ________________________________________________________________________________ Street and Number ______________________ _____________________ __________ _______________ City State or Province Postal Code Country ________________ _________________ ______________________________________ Telephone Telefax e-Mail Address Please explain when and how you came to know the nominee and the extent of your familiarity with her or his work (Add pages or resumes as needed): ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ III. NOMINEE REFERENCES Please provide the names, addresses, and contact information for three individuals who are familiar with the clinical and other contributions of the person you have nominated for the Award. Reference #1 ______________________ ________________ ______________________________________ First Name Middle Name Last Name Professional Title or Institutional Affiliation: ________________________________________________________________________________ Please provide a mailing address, telephone, and telefax number(s), and an e- Mail address where we may contact this person ________________________________________________________________________________ Street and Number ______________________ _____________________ __________ _______________ City State or Province Postal Code Country ________________ _________________ ______________________________________ Telephone Telefax e-Mail Address Reference #2 ______________________ ________________ ______________________________________ First Name Middle Name Last Name Professional Title or Institutional Affiliation: ________________________________________________________________________________ Please provide a mailing address, telephone, and telefax number(s), and an e- Mail address where we may contact this person ________________________________________________________________________________ Street and Number ______________________ _____________________ __________ _______________ City State or Province Postal Code Country ________________ _________________ ______________________________________ Telephone Telefax e-Mail Address Reference #3 ______________________ ________________ ______________________________________ First Name Middle Name Last Name Professional Title or Institutional Affiliation: ________________________________________________________________________________ Please provide a mailing address, telephone, and telefax number(s), and an e- Mail address where we may contact this person ________________________________________________________________________________ Street and Number ______________________ _____________________ __________ _______________ City State or Province Postal Code Country ________________ _________________ ______________________________________ Telephone Telefax e-Mail Address IV. SECURITY AND CONFIDENTIALITY REQUIREMENTS 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, please write "NONE". ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ V. FOR FURTHER INFORMATION For questions, additional information, or to request additional forms, please contact us through the following numbers, or by writing to the address at the bottom of this page. Telephone: 907-966-2600 e-Mail: information@barbarachesteraward.org VI. MAILING ADDRESS AND DEADLINE Should you wish to mail a hard copy of this nomination form, along with any additional pages and enclosures, please send to the address below. Mailings must be postmarked no later than April 30, 2006. Online submissions are, however, preferred. The Barbara Chester Award ò Hopi Foundation Post Office Box 617 Sitka, Alaska 99835 U.S.A.