Down Syndrome International (DSi) APPLICATION FORM - NOMINATION FOR WORLD DOWN SYNDROME DAY (WDSD) AWARDS - SCIENTIFIC December 2014 UK Company Number: 04327941 UK Charity Number: 1091843 DSi Application Form - WDSD Awards - Scientific - Edition 1 1
PRELIMINARY NOTES AND CRITERIA FOR NOMINATION DSi will announce awards in the scientific category to coincide with WDSD on 21 March each year. Any member or member organisation can nominate an individual, group or organisation whose activities have contributed to scientific advancement related to Down syndrome. To make a nomination, please complete the following application form where required, providing as much detail as possible. Detailed responses will assist DSi in assessing your application by comparison with other nominations received. DSi will accept nominations of individuals, groups and organisations. Please note that in order to nominate an individual, group or organisation for a WDSD Award you must be a member of DSi. If you are currently not a member of DSi please email contact@ds-int.org and we will contact you with DSi membership information. It is possible to nominate yourself, given of course that you are a member of DSi. Please restrict your responses to the spaces provided. Should you wish to provide further details, please do so on a separate sheet of paper using the question numbering on this form and send this with your completed application form. Please send your completed application form, together with any additional responses and supporting information, either: By email to: Or by post to: contact@ds-int.org Down Syndrome International, Sowton Business Centre, Unit 2 Capital Court, Bittern Road, Exeter EX2 7FW, United Kingdom Please note the application form is provided electronically in PDF format. If you are not able to print, complete and scan or post documents, please email contact@ds-int.org and we will provide a Microsoft Word version which you can complete and return to us by email. Nominations must be received by the 31 January each year in order to be considered for an award on 21 March in the same year. DSi Application Form - WDSD Awards - Scientific - Edition 1 2
APPLICATION FORM 1. Details of NOMINATOR (to be completed if you are nominating an individual, group or organisation for a WDSD award) 1.1 Contact details of nominator: Contact name: Daytime telephone number (including country code): Email address: 1.2 Your DSi membership number: 1.3 List the names of any groups or organisations you represent or are affiliated to with an interest in Down syndrome (if any): 1.4 Your relationship to the individual, group or organisation you are nominating: 2. Details of the NOMINEE for a WDSD Scientific Award 2.1 Contact details of nominee: Contact name (individual, group or organisation): Daytime telephone number (including country code): Email address: Postal address including country: DSi Application Form - WDSD Awards - Scientific - Edition 1 3
2.2 Please tick which category is applicable; there are 3 categories of award: Clinical or medical professional; Person or persons involved with scientific research related to Down syndrome; Organisation concerned with scientific matters relevant to Down syndrome. 2.3 Briefly describe the activities undertaken by the nominee, focusing on their specific participation and contribution. 2.4 Explain the manner in which the activities were performed (e.g. through mobilisation of resources, fostering innovative ideas, displaying and encouraging skills required for the activities, displaying leadership skills or skills unique to the nominee, time and effort spent by the nominee on the activities). The nominee must have played a key role in the activities. DSi Application Form - WDSD Awards - Scientific - Edition 1 4
2.5 Explain how the nominee s participation and contribution has contributed to scientific advancement related to Down syndrome. 2.6 Describe the ways (if any) in which the local, national, regional or international community has benefited from the work of the nominee. Any positive impact of the activity must be quantified in some way. DSi Application Form - WDSD Awards - Scientific - Edition 1 5
2.7 Include any other information which you believe to be relevant in terms of the contribution of the nominee to scientific advancement related to Down syndrome. DSi Application Form - WDSD Awards - Scientific - Edition 1 6
SELECTION CRITERIA, PUBLICITY AND PRESENTATION All nominations will be evaluated by the DSi Board of Trustees and the DSi Board reserves the right to allocate nominations to another category if appropriate. The DSi Board will follow an evaluation procedure utilising criteria including, but not limited to: The overall contribution of the activity or programme to scientific advancement related to Down syndrome; The suitability, innovation, duration and impact of the activity or programme; The uniqueness of the nominee s contributions and commitments and their willingness to work with others; Where appropriate, the nominee s leadership role in the activity or programme; Where appropriate, an established record of publication in scholarly journals; Where appropriate, the challenges and/or barriers the nominee has had to overcome in the course of the activity. The DSi Board may choose to award a number of nominees per category in any given year or may choose not to present any awards if appropriate. Note that the judgment of the DSi Board of Trustees is final and no appeal will be entertained. We hope that the award recipients will accept their awards, will allow us to present them with a certificate and will provide a brief acceptance statement which we can publicise, together with some details of their activities, via our DSi and WDSD websites and social media pages and to our international members and contacts. In addition we will also invite them to formally receive their awards at the next World Down Syndrome Congress if they are planning to attend this event. Please sign the declaration below to confirm: DECLARATION 1. That the information you have provided in your responses to this application form are truthful and correct; 2. The application form and details of your nomination will remain confidential until the award recipients are formally announced by DSi; 3. If the nominee is successful, you agree that DSi will publicly announce that you nominated this award recipient. Print name: Date: Signature: DSi Application Form - WDSD Awards - Scientific - Edition 1 7