University of Waikato Staff Awards
Health and Safety Excellence Award
Nomination Form
Please use this form for all nominations, to ensure as far as possible that full and systematic consideration can be given by the Staff Awards
Committee to all nominations. Please use a separate form for each nomination and attach additional information as required. Forward the
completed form along with a copy of current position descriptions for each nominee to Mike Bell, Professional and Organisational Development
Unit, no later than the last Friday in October.
N O MI N EE D ET A I L S
Full name(s):
Department(s):
B A S IS F OR N O MI N A TI O N
Please provide a brief (no more than 1000 words) overview of the contribution made by the staff
member(s). Attach a separate document if necessary.
Health and Safety Excellence Award Nomination Form - Staff Awards Committee – May 2016
Form SMA06
University of Waikato Staff Awards
Health and Safety Excellence Award Nomination Form
A
EV A L UA T I ON O F S I G NI F IC A NC E
Please provide your evaluation of the significance and excellence of this contribution.
SU PP OR T IN G EV ID ENC E
Please cite any other (including external) evaluations of the significance and excellence of the contribution
and attach documentation where available. Please ensure that you attach a current position description for
each nominee.
OT H ER S U PP OR T
Please provide details of others who have been consulted and who support this nomination.
Have you attached a current position description for each nominee?

YES

NO
I confirm that the nominated individual or team is suitable for an award.
Senior Manager’s name:
Signature:
Date:
Please note that this nomination must be signed by the relevant Dean, Head, or equivalent senior manager. The evidence provided in support of
this nomination will be used to select a Health and Safety Excellence Award recipient.
Health and Safety Excellence Award Nomination Form - Staff Awards Committee – May 2016
Form SMA06