IN-APSE Employer Award

2011Annual Award Nomination Form

SUBMITTED BY:

APSE Membership must be current. (Please print):

Name of person making the nomination

Mailing addressCity, State, Zip

Area code and daytime phone APSE Membership Number Relationship to nominee

NOMINEE:

Name of NomineeArea code and daytime phone

TitleCompany

Mailing AddressCity, State, Zip

Email Address

DEADLINE

Complete this form and submit with supporting statements by mail no later than October 15th, 2011 to:

Ron RoembkeEmail:

Easter Seals CrossroadsPhone: (317) 466-1000 ext. 2434

4740 Kingsway DriveFax: (317) 466-2000

Indianapolis, IN46205

PURPOSE

To confer recognition on employers in the public and private sectors for outstanding achievements in enhancing employment opportunities for people with disabilities.

ELIGIBILITY

This award is given to employers who demonstrate outstanding achievements in promoting supported employment, making accommodations, and including people with disabilities in their place of work.

NOTE: When answering these questions, please include as many specific examples as possible to help “tell the story” of why this employer deserves to win this award. Please use a separate sheet of paper if necessary.

EVALUATION

Describe the nominee’s policies pertaining to employment of persons with disabilities.

______

What are the procedures and sources for outreach and recruitment, placement, training and career advancement of employees with disabilities?

______

What specific efforts, if any, have been made to accommodate workers with severe disabilities? Give specific examples.

______

Has there been any special orientation or training for supervisors to ensure an effective working relationship between supervisors and employees with disabilities?

______

If unionized, are there any labor-management agreements that facilitate employment of people with disabilities?

______

What has the employer done to ensure that employees with disabilities have been fully integrated in the company’s work force?

______

Has the nominee made a concerted effort on the local, state, and/or national level to encourage other employers to hire people with disabilities?

______

In what ways do the nominee’s achievements exceed legal requirements? Give specific examples.

______

NOTE: All nominations must include two letters of support. One letter must be from an employee at the same firm and the other letter from an employee with a disability who also works at the same firm. (Please attach to this form). THANK YOU!