Adopt-a-Cop Annual Awards

2013 Nomination Form

Instructions for completing this form:

Nominations can be made by members of the school community, including teachers and other school staff, parents, students, and Queensland Police Service (QPS) employees including Adopt-a-Cops nominating themselves.

Criteria for nomination:

1.The nominated Adopt-a-Cop must be formally adopted by the primary or secondary school or educational institution.

2.The nominated Adopt-a-Cop must have performed their role in an outstanding manner and, in doing so, have built/maintained a positive relationship between police and the students, teachers and parents/carers of the school community.

Section 1: Nomination Details should be completed by the nominator and forwarded to either the School Principal or Officer in Charge of the Police Station in which Division the school is locatedby 7 June 2013. If the nominee is the Adopt-a-Cop at more than one school, it should be submitted to one of the relevant School Principals or Officers in Charge for comment and forwarding as instructed.

Section 2: Mandatory Referees should be completed by both the Officer in Charge of the Police Division in which the school is located and the School Principal or their representative. If the nominee is the Adopt-a-Cop at more than one school, this section is only required to be completed by one Officer in Charge and one School Principal or their representative.

Once completed, the Principal or Officer in Charge is requested to seek further comment/s from additional referees in Section 3.

Section 3: Elective Referees. An unlimited number of elective referees are invited to provide comment about the nominee in relation to Criteria 2, as well as to outline specific outcomes achieved. If the nominee is the Adopt-a-Cop at more than one school consideration should be given to forwarding this form to the other school/s and Officer/s in Charge for comment.

Note: Sections 2 and 3 should not exceed two A4 pages (i.e. pages 2 and 3 of this form). Comments may be handwritten or typed. Font sizes must not be smaller than 10.

Section 4: Nominee Submission should be completed by the nomineeAdopt-a-Copto verify the claims made by referees and provide relevant additionalinformation.

Section 5: Supporting Documentation.Nominees are invited to submit supporting documentation which may include photographs, video footage, POPP project reports, other reports and messages from students. All supporting documentation should be submitted with this form and remain with this form throughout the judging process. Once completed the nominee should submit the form to their District Crime Prevention Coordinator by no later than 21 June 2013.

SECTION 1: NOMINATION DETAILS

Name of AAC nominated:______Rank: ______

Station/Section: ______

School: ______Date of Adoption (if known)______

Nominated by:______Position:______

School/Police Station:______Telephone: ______

SECTION 2:MANDATORY REFEREES

Officer in Charge of Division where school is located

Comment:

Name: ______Rank: ______Station: ______

Date: ______Signature: ______

School Principal or relevant representative

Comment:

Name: ______Rank: ______Position: ______

Date: ______Signature: ______

SECTION 3: ELECTIVE REFEREES

Additional referee 1

Comment:

Name: ______Position: ______

Date: ______Signature: ______

Additional referee 2

Comment:

Name: ______Position: ______

Date: ______Signature: ______

Additional referee 3

Comment:

Name: ______Position: ______

Date: ______Signature: ______

SECTION 4: NOMINEE SUBMISSION

  1. How long have you performed Adopt-a-Cop duties (whether formally adopted or not)? ______
  1. How long have you been the Adopt-a-Cop at your current school/s? ______
  1. I am able to verify the comments made by both the mandatory referees and elective referees?

Yes No Somewhat (please comment) ______

Please provide additional comments regarding your AAC involvement. You may wish to providing information regarding: the number or regularity of your visits; the type of activities undertaken; any particular projects and their outcomes; and/or the outcomes of your general involvement with the school community. Please limit your written response to this page. You are invited to attach supporting documentation with this form. Please ensure any supporting documentation is outlined on page 5.

SECTION 5: SUPPORTING DOCUMENTATION

  1. ______
  1. ______
  1. ______
  1. ______
  1. ______
  1. ______
  1. ______
  1. ______
  1. ______
  1. ______

QPS Adopt-a-Cop Awards Nomination Form 2013 Page 1 of 5