EXECUTIVE LEADERSHIP AWARD NOMINATION FORM

This nomination recognises the outstanding contribution(s) to LGBTQ+ inclusion by an executive and/or senior leader within your organisation.

Culture is driven from the top, and visible, active executive support for LGBTQ+ inclusion sends a powerful message both internally and externally. Their contributions should reflect work undertaken across both internal and external contexts, reinforcing inclusion to potential employees, service users, customers, clients, stakeholders, LGBTQ+ communities engaging with your organisation, and the broader public.

Annual HWEI Survey data demonstrates that visible and active senior allies have a significant impact within organisations. Executive and leadership visibility in LGBTQ+ inclusion positively influences health, wellbeing, inclusion, and acceptance. It also helps reduce incidents of bullying and harassment and contributes to environments where individuals feel safer to report and address negative behaviours.

The nominee may hold an Executive Sponsor role; however, their contribution should extend beyond the formal requirements of their position and may include, but is not limited to:

advocacy for the importance of LGBTQ+ networks and their work with senior leaders
priority-setting informed by broader organisational strategy and inclusion objectives
provision of guidance, sponsorship, and organisational insight to support network goals
visible and active support of LGBTQ+ networks, employees, and inclusive service delivery across the organisation

Ultimately, this award recognises leaders who not only champion inclusion, but actively shape a culture where LGBTQ+ people can feel safe and supported in healthcare settings.

This application can be completed and submitted between Monday, 11 January 2027 – Monday, 1 February 2027.

Nominee Contact Details

Please provide the details below exactly as you would like them to appear on Awards materials, including social media, website, announcements, publications, and trophies (where applicable).

Please review all information carefully before submitting. ACON's Pride Inclusion Programs will reproduce names and details exactly as submitted and cannot accept responsibility for any inaccuracies in the nomination form.

Name *

Pronouns *

Employer/Organisation Name *

Position Title *

Primary Contact Email *

Nominator Contact Details

Name *

Primary Contact Email *

Disclosure

Please confirm BOTH of the following: *

The nominee is aware of this nomination and has given you permission to proceed.The nominee consents for any images or information provided in this nomination to be used in Awards materials including social media, website, announcements, event program, and trophy (if applicable).

How to Complete Your Nomination

'Save and Complete Later' Function:

IMPORTANT: Use the 'Save and Complete Later' function as you complete your nomination. This function can be utilised throughout the year, as you prepare, review and complete.
This function allows you to return to your work without losing any work previously updated.
If you do not use this function, any changes or updates made may not be saved and work may be lost. Pride in Diversity will not be responsible for any work lost.
Upon clicking 'Save and Complete Later,' you will be sent a link to utilise to return and continue work on your nomination.

'Submit' Function:

Once you have completed and reviewed all work and areready to submit, you must click the 'Submit' button upon completion.
If you do not click 'Submit' upon completion, your nomination will not be accepted.
Do not click the 'Submit' function unless you are ready to formally complete and submit your nomination.

Placeholder Link Function:

Each time you click 'Save and Complete Later,'you will be sent an updated link to continue you work on your nomination. Any work done on an 'outdated' link will result in work being lost.
Any link provided to you and your organisation can only be utilised by those within your organisation.
If multiple people are working on a nomination for their organisation, they must share this correctlink or all work will not be saved properly. Each placeholder link email will be sent to the person who is working on the nomination at time of saving.

Internal Support

The nominee is acknowledged as an Executive Champion or Sponsor for LGBTQ+ inclusion within our organisation, exceeding the expectations of this role.

The nominee has communicated support for LGBTQ+ inclusion to all employees via all-staff emails, all-staff forums or other all-staff communications.

The nominee has attended internal LGBTQ+ inclusion events.

The nominee has advocated for or spoken of our work in LGBTQ+ inclusion at the board level.

The nominee has taken an active interest in the organisational progress regarding LGBTQ+ inclusion or in the setting of relevant targets and/or objectives.

The nominee has actively sought to understand challenges faced by LGBTQ+ service users and their experiences within our service.

If you wish to provide evidence to support your responses above, please do so here:

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Only one attachment per field.

External Support

The nominee has communicated support for LGBTQ+ inclusion in media interviews.

The nominee has attended external LGBTQ+ workplace inclusion events.

The nominee has spoken at external LGBTQ+ inclusion events regarding LGBTQ+ inclusive service delivery.

The nominee has advocated for or spoken of our work in LGBTQ+ inclusion with CEOs/peers external to the organisation.

The nominee has participated in LGBTQ+ community events.

The nominee has voiced support for social inclusion issues impacting the LGBTQ+ community.

If you wish to provide evidence to support your responses above, please do so here:

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Only one attachment per field.

References

Written references are required in support of the nomination. Please provide the written references below, along with the name and position title of each referee.

Please do not provide only contact details without including a written reference.

Please provide one reference from the CEO (or equivalent) in support of this nomination.

Referee Name

Position Title

Please provide one reference from peer colleagues (e.g., other Executives from the Senior Leadership Team) in support of this nomination.

Referee Name

Position Title

Please provide one reference from an LGBTQ+ employee in support of this nomination.

Referee Name

Position Title

Additional Work

Please identify any additional information, not covered previously that you would like to include in support of this nomination.

Title of Work

Answer

Title of Work

Answer

Title of Work

Answer

Title of Work

Answer

If you wish to provide evidence to support your responses above, please do so here:

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Only one attachment per field.

Finalist / Winner Statement

In a short paragraph, explain why this nominee specifically deserves recognition in this category, highlighting key achievements and impact in LGBTQ+ inclusive service delivery. This statement will be used in Awards materials if they are selected as a finalist or winner. *Should this nominee become the recipient of this award, this statement will be read at the Australian Pride in Health + Wellbeing Awards.

Nominee Photo

Please provide a clear hi-resolution image of the nominee. Should they be selected as a finalist or winner within the category, this image may be used in Awards materials including social media, website, announcements and during the Awards ceremony. *

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Only one attachment per field. File should be at least 1MB and minimum 2000 × 2000 pixels. Please do not upload social media profile images downloaded from websites (such as LinkedIn), as these are too low resolution to be used in Awards materials.

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