2016 PIRC PRACTITIONER AWARD NOMINATION FORM

NOMINEEPlease provide the name, address, phone number, email addresses, current place of employment and position title, personal Twitter Handle, and personal website of the nominee.Name: Phone Number:

Street Address: City/State/Zip Code:

Work Email Address: Personal Email Address:

Current Place of Employment: Position Title:

Website: Twitter Handle:

AWARD NOMINATION NARRATIVE In no more than 1200 words (PDF or Word), provide specific, concrete examples for ONE of the selection criterion in category A, and at least ONE of the criteria in category B. Include a detailed narrative explaining the candidate’s service, including:

Selection Criteria A: The PIRC PRACTITIONER AWARD is presented to an individual who has

Advanced the field through evidence-based practice

Improved the prevention of and response of systems to gender-based violence, including sexual and relationship violence and stalking

increased public awareness and knowledge about the incidence, causes and contributing factors, and nature of sexual and relationship violence and stalking

Selection Criteria B: Recipients of the PIRC PRACTITIONER AWARD must have demonstrated An understanding of the effects of

trauma on victims The ability to address existing problems

and gaps in prevention, services or other responses with innovative trauma-informed solutions

An understanding of gender-based violence, including sexual and relationship violence and stalking as social justice issues

Include a detailed narrative explaining the candidate’s service, including: how the nominee's service is outstanding or extraordinary the time frame during which this work was performed why this work has mattered; an assessment of the impact

CANDIDATE BIO OR RESUMEPlease attach the nominee’s resume or biography. Maximum two pages (in PDF or Word).

REFERENCES Please provide the name, place of employment & title, email address and phone number of three persons who are familiar with the nominee's achievements and who are willing to be contacted by the selection committee in order to serve as a reference for the nominee.

Reference 1. Name:

Place of Employment & Title: Email Address: Phone Number:

Reference 2. Name:

Place of Employment & Title: Email Address: Phone Number:

Reference 3. Name:

Place of Employment & Title: Email Address: Phone Number:

NOMINATING ORGANIZATIONPlease provide the name of the nominating organization and contact person.Organization’s Name: Organization City:

Contact Person Name: Contact Person Title:

Contact Person Daytime Phone Number: Contact Person Email Address:

Contact Person should check this box to indicate that s/he attests that the information contained in this application is true to the best of her/his knowledge and the Nominating Organization has authorized this Nomination.

EMAIL NOMINATION PACKAGE Submit this form and required attachments via email, no later than Friday, October 14th 2016, to: Prevention.Innovations@unh.edu. Be sure that your email includes the words, Award Nomination, in the Subject line.