Award Nomination Form

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Indigenous Eye Health (IEH) at the University of Melbourne is hosting the Close the Gap for Vision by 2020: Striving Together – National Conference 2018 on Thursday 15 and Friday 16 March 2018 at The Arts Centre, Melbourne.

The 2018 conference will showcase the progress in Close the Gap for Vision activities, illustrate and workshop solutions to overcome challenges and highlight especially what can be achieved by ‘striving together’ towards the 2020 goal of equity in eye care for Aboriginal and Torres Strait Islander people.

It is important to recognise people and organisations that are working to Close the Gap for Vision and have made a significant contribution over the years or achieved a significant outcome in that work.

As a part of the conference IEH has decided to provide this recognition by inaugurating the 2018 Leaky Pipe Awards.

IEH invites nominations to recognise and celebrate the achievements of individuals and groups in progressing activities to Close the Gap for Vision.

Please fill in all the fields below and click the submit button to finalise your nomination

Your Contact Details

Name *

Organisation *

Phone Number * Please include area code (e.g. +614)

Email *

Nomination Details

Name of Individual/ Group/ Organisation *

Organisation (If applicable)

Phone number of key contact for Individual/ Group/ Organisation * Please include area code (e.g. +614)

Email of key contact for Individual/ Group/ Organisation *

Referee

Name *

Organisation *

Phone Number * Please include area code (e.g. +614)

Email *

Statement of support

Statement to support nomination *

Note: A copy of your submission will be sent to the email you provided.