Barbara Chester Award

Nomination Form

INSTRUCTIONS FOR USING THIS FORM
  1. Required Information. Please fill-in all of the required information. Required information is labeled in bold red. You cannot transmit the form to us until all of the required information has been completed.
  2. Narrative Answers. Several questions require a narrative, answer. There are two methods for submitting narrative answers.

    3. A. The form contains text boxes that allow you to type-in narrative answers. Your answer may contain as many words as you need to use.

    B. You may send attachments such as resumes, curriculum vitae, additional pages for narrative answers, or representative samples of publications by mail, and we encourage you to do so even if you have filled-in this online form. If submitting the Nomination form online and sending additional attachments by mail, please type or print the nominee's name and your name on each page you send by mail.

  • 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 your nomination was received on the website. If you do not receive this acknowledgement, please contact us.
    		•
    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:

    Month
    Day
    Year
    Place of Birth:

    City
    State or Province
    Country
    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

    Month
    Day
    Year
    Past Employment
    Please list and describe

    (Send additional 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 or 2-Year Degree
    Years Completed
    Field of Study
    		Bachelor's or 4-Year Degree
    Degree
    Major
    Graduate Degree(s)
    Please list and describe

    (Forward pages or resumes as needed)
    Other Degree(s) or Training (or Internships/Apprentices)
    Please list and describe

    (Forward pages or resumes as needed)
    Publications by the Nominee
    Please forward a resume or curriculum vitae, or list representative publications, if relevant.
    Please list and describe
    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. 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 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

    (Forward additional pages or resumes as needed)
    II. THE NOMINATOR

    Nominated by:

    First Name
    Middle Name
    Last Name

    Your Professional Title and 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:

    (Forward additional pages or resumes as needed)
    III. NOMINEE REFERENCES (optional)

    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 and 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 and 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 and 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 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.
    NONE
    If there are any concerns about confidentiality, please describe:
    V. FOR FURTHER INFORMATION
    For questions or additional information, please contact us through the following website, email address, or phone number, or by writing to the address at the bottom of this page.
    Telephone :
    e-Mail :
    Internet:
    		 907-966-2600
    information@barbarachesteraward.org
    http://www.barbarachesteraward.org/
    VI. MAILING ADDRESS
    When completed, please mail this form, along with any additional pages and enclosures, to the address below.
    The Barbara Chester Award • Hopi Foundation
    Post Office Box 617
    Sitka, Alaska 99835 U.S.A.


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    The Hopi Foundation