The Recipient Will Receive Registration Fees, Travel and Accommodation to Attend PAC13

This award is to recognise a pharmacist who has made an outstanding contribution to the quality use of medicines through direct clinical care of consumers with persistent pain.

The recipient will receive registration fees, travel and accommodation to attend PAC13.

Applicants must be a current PSA member to qualify for the award.

The PSA Award for QUM in Pain Management has been supported by a grant from Mundipharma.

Please complete and return this form by 2 August 2013 to:

Program Manager Professional Development
Pharmaceutical Society of Australia
Level 1. 381 Royal Parade
Parkville VIC 3017

Fax: 03 9389 4044
Email:

PSA will use the information in this application form to determine the award recipient and will handle all material in accordance with PSA’s privacy policy – available on

Applicant details
Date of application
Applicant name
PSA member number
Postal address
Workplace name
Contact email
Contact phone number
Practice area(s) in which you provide direct clinical care /  Non-prescription medicines and therapeutic devices
 Dispensing
 Medication review
 Disease state management
 Other (please specify)

Applications will be adjudicated against a selection of the goals of the National Pain Strategy. The Strategy can be downloaded from

Please describe how strategies you have implemented in your area of practice contribute to achieving one or more of these key goals. Maximum word limit per goal is 500 words.

Goal 1. People in pain as a national health priority
Goal2. Knowledgeable, empowered and supported consumers
Goal 3. Skilled professionals and best-practice evidence-based care
Goal 4. Access to interdisciplinary care at all levels
Goal 5.Quality improvement and evaluation
Declaration
I declare that, to the best of my knowledge, the information contained within my application is a true reflection of my practice.
Signature: ...... Date: ......