ID ______

(For OLT use only)

Nomination Form

2014 Award for Programs that Enhance Learning

Please read the Australian Awards for University Teaching (AAUT)Privacy Notice p. 3 before completing this form.

  1. Program information

Program name (not more than ten words)

Institution(if more than one institution, please list)

Program discipline and start date

Where the program has a discipline focus, please list theASCED classification Broad and Narrow Field of Education number/s.

Discipline:

The program started on / /

  1. Contact details (for nominee or lead of the team)

Title (e.g. Professor)
First and last name
Position title
School/ department/ faculty
Institution
Campus of the nominee
Postal address
Email address
Telephone
Staff type check (X) one box / Academic staff General staff
Gender check (X) one box / Female Male
  1. Categories

Nominate ONE category –see Nomination Instructions for descriptions.

1.Widening participation

2.Educational partnerships and collaborations with other organisations

3.The first-year experience

4.Flexible learning and teaching

5.Innovation in curricula, learning and teaching

6.Postgraduate education

7.Services supporting student learning

8.Global citizenship and internationalisation

  1. Team nominations

Please list all members – if more than eight members, a separate list may be attached. Names and titles must be accurate for publication purposes. All teams must have a team name. The contribution of each member should be expressed as a percentage. The total of all members’ contributions to the activity or program should not exceed 100 per cent.

Team name
Title / First and last name / Percentage contribution / Staff type (A/G)
A - Academic
G - General Staff
Total / 100%
  1. Previous engagement with the Australian Awards for University Teaching program

If the nominee or the lead in a team nomination has previously received an Award or Citation, please indicate the type of award, the year in which it was received and how it differs from this nomination.

  1. Privacy Notice – Australian Awards for University Teaching

When a nomination for an Award or Citation under the AAUT programhas been submitted, the OLT in theDepartment of Education (the Department), will collect your full name, gender, job description, contact details, institutional postal address, photo and curriculum vitae (if required).

The OLT is collecting this information to assess your nomination for an Award or Citation, and to undertake statistical analysis in relation to the OLT’s Awards programs.The Department may use your personal information to:

  • confirm your eligibility for an Award or Citation
  • maintain an ongoing relationship with you
  • award prizes
  • invite you to relevant OLT events and programs
  • review or evaluate the AAUTprograms.

If you receive an Award or Citation, the Department may publish your personal information (excluding telephone contact details) in: media releases; presentations; conference programs; booklets about the AAUT recipients; OLT programs; and on the OLT orthe Department’s website. The OLT will also maintain your details for possible future selection as an assessor for OLT programs. For these purposes, the Department may also disclose your personal information to the following persons and organisations:

  • your nominating institution or the Minister’s Office
  • persons assessing the nominations
  • Standing Committee members and Strategic Advisory Committee members
  • event and program contractors performing services on behalf of the Department.

The Department will not use or disclose your personal information for any other purpose unless permitted by the Privacy Act 1988.

Please notify the OLT by email if your contact details, or those of your institution change.

  1. Nominee’s declaration

I /We (print name of nominee or team leader)
..………………………………………………………......
accept nomination for an Award for Programs that Enhance learning
Signature / Date / / 2014
  1. Head of Faculty’s support for nomination and authorisation

I support this nomination on the basis of the attached application. I confirm that the contact details provided are correct and that the nominees referred to on this form are currently members of this Faculty’s teaching staff.
Title
First and last name
Position
Faculty
Signature / Date / / 2014
  1. Vice-Chancellor/ Chief Executive Officer’s declaration

On behalf of this institution, I support this nomination on the basis of the attached application. This institution undertakes to support the nominees in activities to disseminate good practice in learning and teaching. I confirm that the information above is true and correct, and the nominees referred to on this form are currently staff members or associates of this institution.
Title
First and last name
Position
Signature / Date / / 2014
  1. Institutional Contact Officer

Name(print)
Position title
Email address / Telephone
Signature / Date / / 2014

Office for Learning and Teaching – 2014 Program Award Nomination Form v1.1 1