CUPE Ontario Injured Workers Advocacy Award Nomination Form

Closing date for nominations is April 30, 2025.

Do you know a member who has made a significant contribution on behalf of injured workers?

CUPE Ontario’s Injured Worker Advocacy Committee wants to hear from you for their Injured Worker Advocacy Award.

The award shall be presented at CUPE Ontario’s Annual Convention.

The Committee seeks candidates:

Whose actions have helped others;
Whose activities have:
1. Improved conditions for injured workers, inside and outside the workplace;
2. Helped recognize occupational illnesses or diseases;
3. Solved problems;
4. Advocated on behalf of injured workers’ rights;
5. Achieved victories for injured workers;
6. Established precedents.
Who have been a leader and/or activist on behalf of injured workers.
Who are members in good standing of a CUPE Ontario-affiliated local.

Please note that CUPE staff and members of CUPE Ontario’s Injured Workers Advocacy Committee who sit on the Award Selection Committee are not eligible for the award.

Nomination Form

Name of Nominee *

Local Union Number *0 / 9

Mailing Address:

Street Address *

Apartment, suite, etc

City *

Province *

Postal Code *

Home Phone *

Work Phone

Occupation *

How many years has the nominee been a CUPE member? *

Submitted By:

Name of Submitter *

Local Union Name *

Local Union Number: *

Mailing Address:

Street Address *

Apartment, suite, etc

City *

Province *

Postal Code *

Home Phone *

Work Phone

Fax Number

Email Address *

Local President Name *

The President of this local has given their endorsement to submit this nomination form.

Yes

Local or Division Executive Member's Name *

A Local or Division Executive Member (who is not the president) has also given their endorsement to submit this nomination form.

Yes

Involvement

Local Union Injured Worker Advocacy

Workplace Joint Injured Worker Committee

WJIWC Current

WJIWC Past (Years)

WJIWC Comments

Local Injured Worker Advocacy Committee

Local IWAC Current

Local IWAC Past (Years)

Local IWAC Comments

CUPE Ontario Division Injured Worker Advocacy Committee

CUPE Ontario IWAC Current

CUPE Ontario IWAC Past (Years)

CUPE Ontario IWAC Comments

Other (e.g.: Labour Council, CUPE District Council, etc.)

Other Local Union Current

Other Local Union Past (Years)

Other Local Union Comments

Local Union (General)

Steward/Injured Worker Advocate

Steward/IW Advocate Current

Steward/IW Advocate Past (Years)

Steward/IW Advocate Comments

Local Executive Member

Local Executive Member Current

Local Executive Member Past (Years)

Local Executive Member Comments

Committees (e.g.: Injured Worker Advocacy, Health and Safety)

Committees Current

Committees Past (Years)

Committees Comments

Other (e.g.: Negotiated WSIB language into CBA, etc.)

Other Local Union Gen. Current

Other Local Union Gen. Past (Years)

Other Local Union Gen. Comments

Contribution to Injured Workers at the Local Union Level

Please tell us how the nominee has made a positive contribution in the field of injured worker advocacy at the local union level. Include what the nominee has done, how it was achieved, where, when, and any success stories you wish to share.

What has the nominee done? (Contribution to Injured Workers at the Local Union Level)

How was it achieved? (Contribution to Injured Workers at the Local Union Level)

Where? (Contribution to Injured Workers at the Local Union Level)

When? (Contribution to Injured Workers at the Local Union Level)

Other Contributions to Injured Worker Advocacy

Please tell us if the nominee has contributed to injured worker advocacy at the Ontario Division level. Include what the nominee has done, how it was achieved, where and when.

What has the nominee done? (Other Contributions to Injured Worker Advocacy)

How was it achieved? (Other Contributions to Injured Worker Advocacy)

Where? (Other Contributions to Injured Worker Advocacy)

When? (Other Contributions to Injured Worker Advocacy)

OFL—Occupational Disability Response Team Training

WSIB and Other Related Training

Has the member completed any portion of the Mohawk College WSIB-related training or Labour Studies program? If yes, please provide a detailed list here:

Other Relevant Courses/Workshops

Please use this space to list any other relevant courses or workshops the nominee has taken.

Closing date for nominations is April 30, 2025.

Do you know a member who has made a significant contribution on behalf of injured workers?

The Committee seeks candidates:

Please note that CUPE staff and members of CUPE Ontario’s Injured Workers Advocacy Committee who sit on the Award Selection Committee are not eligible for the award.

Nomination Form

Mailing Address:

Submitted By:

Mailing Address:

The President of this local has given their endorsement to submit this nomination form.

A Local or Division Executive Member (who is not the president) has also given their endorsement to submit this nomination form.

Involvement

Local Union Injured Worker Advocacy

Local Union (General)

Contribution to Injured Workers at the Local Union Level

Other Contributions to Injured Worker Advocacy

OFL—Occupational Disability Response Team Training

Level 1—Rights and Obligations

Level 2—Benefits and Representation

Level 3—Appeals and Dispute Resolution

Level 4—Return to Work Program

Level 5—Medical Orientation

Level 6—Occupational Disease

WSIB and Other Related Training

Other Relevant Courses/Workshops

CUPE Ontario Injured Workers Advocacy Award Nomination Form

Closing date for nominations is April 30, 2025.

Do you know a member who has made a significant contribution on behalf of injured workers?

The Committee seeks candidates:

Please note that CUPE staff and members of CUPE Ontario’s Injured Workers Advocacy Committee who sit on the Award Selection Committee are not eligible for the award.

Nomination Form

Mailing Address:

Submitted By:

Mailing Address:

The President of this local has given their endorsement to submit this nomination form.

A Local or Division Executive Member (who is not the president) has also given their endorsement to submit this nomination form.

Involvement

Local Union Injured Worker Advocacy

Local Union (General)

Contribution to Injured Workers at the Local Union Level

Other Contributions to Injured Worker Advocacy

OFL—Occupational Disability Response Team Training

Level 1—Rights and Obligations

Level 2—Benefits and Representation

Level 3—Appeals and Dispute Resolution

Level 4—Return to Work Program

Level 5—Medical Orientation

Level 6—Occupational Disease

WSIB and Other Related Training

Other Relevant Courses/Workshops

Thanks for participating