National Award for Community Service Nominations 2025 You may use this offline (PDF form) to download and submit instead of completing the form below. Details of the applicantTitle*Surname*Given Names*Postal Address* Postal City*Post Code*Position / TitleOrganisation / Business NameOrganisation/Business Address Organisation / Business CityOrganisation/Business Post CodeHome PhoneBusiness PhoneMobile Phone*Email* Details of the nomineeTitle*Surname*Given Names*Postal Address* Postal City*Post Code*Organisation / Business NameOrganisation/Business Address Organisation / Business CityOrganisation/Business Post CodeHome PhoneBusiness PhoneMobile PhoneEmail ASSESSMENT CRITERIA Your application can be about large or small projects, but most notably you will need to demonstrate how the work you are doing is improving outcomes to reduce road trauma and its direct impacts either locally, regionally or nationally in New Zealand. To be competitive your application must address each of the following criteria, and provide evidence that substantiates its claims. The criteria used to assess and judge the submissions to all situations. For each project, the New Zealand Road Safety, Emergency Response and Healthcare Awards Executive Executive Committee will focus on the following criteria: ACTS OF COMMUNITY SERVICE – ROAD CRASH SITE PART A 1 - Incident PART B 1 - Action PART C 1 - Outcome ACTS OF COMMUNITY SERVICE – POST ACCIDENT CARE AND RECOVERY PART A 2 - Situation PART B 2 - Service Contribution PART B 3 - Outcome ACTS OF COMMUNITY SERVICE – ROAD CRASH SITE PART A 1 – INCIDENT WHAT WAS THE INCIDENT? 1. Please provide a brief description of the incident where the act occurred. 2. Please note the date, time and location of the incident. 3. DESCRIBE CONDITIONS, (PARTICULARLY IF UNUSUAL OR DANGEROUS) Part A 1 PART B 1 – ACTION 1. PLEASE PROVIDE A BRIEF SUMMARY OF THE RESCUE EFFORTS ON WHAT THE PERSON YOU ARE NOMINATING DID? Please clearly articulate what the person that you are nominating for this Award did. You may wish to elaborate on any elements of risk (if any). Please detail if this person has previous medical, emergency response or first aid experience e.g. paramedic, nurse, police officer This could be supported by links to media articles or other information relevant about the incident. If available, the contact details of any other witnesses to the incident. Part B 1 PART C 1 - OUTCOME WHAT WAS THE INFLUENTIAL DIFFERENCE, CONTRIBUTION OR ASSISTANCE AT THE SCENE OF A ROAD CRASH SITE? 1. Please provide a brief summary of the attributing outcome of the nominee's contribution. Examples may include rendered first aid, vehicle extraction, site communication and co-ordination of emergency services onsite.Part C 1 Upload supporting document(s) Drop files here or Accepted file types: jpg, png, pdf, docx. attach any supporting files to your nomination JPG, PNG, PDF or DOCX formatsACTS OF COMMUNITY SERVICE – POST ACCIDENT CARE AND RECOVERY PART A 2 – SITUATION WHAT WAS THE SITUATION 1. DESCRIBE THE SITUATION AND DESCRIBE HOW IT RELATES TO THE AWARDS CRITERIA. 2. DATE, TIME AND LOCATION OR PERIOD OF CARE. Part A 2 PART B 2 – ACTION OR SERVICE CONTRIBUTION WHAT WAS THE INFLUENTIAL DIFFERENCE, CONTRIBUTION OR ASSISTANCE AT THE SCENE OF A ROAD CRASH SITE? 1. PLEASE PROVIDE A BRIEF SUMMARY OF THE ACTION AND SERVICE CONTRIBUTION OF THE PERSON THAT YOU ARE NOMINATING? Please provide Letter of Support e.g. service provider or District Health Board. Part B 2 PART C 2 - OUTCOME WHAT WAS THE INFLUENTIAL DIFFERENCE, CONTRIBUTION OR ASSISTANCE OF THE NOMINEES SERVICE CONTRIBUTION? 1. 1. PLEASE PROVIDE A BRIEF SUMMARY OF THE HUMAN OUTCOME OF THE NOMINEES CONTRIBUTION.Part C 2 Upload supporting document(s) Drop files here or Accepted file types: jpg, png, pdf, docx. attach any supporting files to your nomination JPG, PNG, PDF or DOCX formats
