by Kirsty Cardy August 4, 2022 eMHIC International LeadershipAward Nominations Play Video About the Nominations Here you can add some information about the nominationsNominate someone below Nomination Form "*" indicates required fields Please select your nomination type:* Myself / My organisation Another Person / Organisation About yourselfName* First Last Role / Profession* Company / Organisation* Country of residence / Where your work is based*AustraliaCanadaNew ZealandSingaporeSwedenUnited KingdomUnited StatesEmail* Phone*Website or Online Profile How do you know the nominee?*About Your NomineeIs your nominee a person or organisation?* Person Organisation Name of Nominee* Nominee's Website or Online Profile Key person of contact at the company / organisation* Key Contact's Email* Key Contact's Phone*Nominee's Role / Profession* Nominee’s company / Organisation Nominee’s country of residence / Where they work*AustraliaCanadaNew ZealandSingaporeSwitzerlandUnited KingdomUnited StatesNominee's Email* Nominee's Phone*About the eMental Health InitiativeWhat is the name of the digital mental health initiative?* Describe the digital mental health initiative*Has this initiative been evaluated for its efficacy?* Yes No Not Applicable Describe why the digital mental health initiative is worthy of this award*Things to consider include; scale, reach to unique population segment, sustainable change, equity and inclusion focus, novel innovation, visionary leadershipWhere has the initiative been implemented?*Please check all that apply Primary Care Secondary Care Tertiary Care Direct to Consumer Public Health Other (Please describe) Please describe where the initiative has been implemented.Apart from the nominee’s primary country, has this initiative been implemented in any other international jurisdiction?* Yes No Please describe where else the initiative has been implemented:Please describe how this initiative is being funded*Government, private funds etcSupporting EvidenceWould you like to provide other reference sites for this initiative? https:// Would you like to upload any supporting documents?e.g. published journal article or white paper, media release, report/evaluation Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB. RefereesPlease provide names and contact details of two referees for your nominee. Referees will only be contacted for shortlisted Nominees.Referee 1Name First Last Email Relationship to Nominee Referee 2Name First Last Email Relationship to Nominee Declaration and Consent* I agree.By ticking this box you agree that all of the information provided in this form is true to the best of your knowledge, and you have consent from third parties to provide information on their behalf. Δ Share TwitterLinkedinEmail
