Organization (Social and Community Service Managers)

Form Approved

OMB No. 0990-

Exp. Date XX/XX/20XX

2010 Healthy Living Innovation Awards NOMINATION FORM Information collected on this nomination form will be used for the purpose of selecting awardees for the Healthy Living Innovation Awards and disseminating information on innovative disease prevention and health promotion programs in various settings. An executive summary of the nomination form for the most promising innovations will be posted on the Healthy Living Innovation Awards website for public viewing as well as made available for dissemination purposes. In addition, the organization information as well as the name of a contact person for the award winners will be made available on the website for replication purposes.
1. Basic Information:
1a. Title of Innovation (Please specify the title of the innovation being nominated. If your innovation is a part of a larger program and does not have a specific title please specify the title of the larger program.)
1b. Inception date (Innovations must have been piloted or implemented within the last three years or be an existing program that has implemented a new innovative practice within the last three years.)
1c. Funding source(s) (Please specify the funding source(s) for the innovation (i.e. internal funding, grants, cooperative agreements, state and local government.) Note: Organizations that have received Federal funding ARE eligible for nomination provided that a non-Federal agency/organization has full responsibility and authority for developing and implementing the innovation. Innovations implemented by individual Federal employees are eligible, provided they are not being implemented as a part of their federal job or the scope of their work.
1d. Yearly Operating Costs for the Innovation
2. Contact Information for the Innovation: *indicates a required field
	* Key Contact Name:
	*Organization:
	*Address 1:
	Address 2:
	*City:
	*State:
	*Country:
	*Zip Code:
	*Phone Number:
	Fax Number:
	*Email Address:
	Website for Innovation:
	Website for Organization
3. Award Category: Please identify the Primary and Secondary categories for award consideration.
3a. Primary Category, Please check one
	□		Faith-Based and/or Community-based Initiatives
	□		Health Care Delivery System
	□		Healthy Workplace (Large Employer - 500 employees or more)
	□		Healthy Workplace (Small Employer - fewer than 500 employees)
	□		Non-Profit
	□		Public Sector (local, state/territorial, tribal) Note: Federal Agencies are NOT eligible
	□		Let’s Move Cities and Towns
	□		Schools (K-12)
3b. Secondary Category (Optional), Please select a secondary category, if applicable
	□		Faith-Based and/or Community-based Initiatives
	□		Health Care Delivery System
	□		Healthy Workplace (Large Employer - 500 employees or more)
	□		Healthy Workplace (Small Employer - fewer than 500 employees)
	□		Non-Profit
	□		Public Sector (local, state/territorial, tribal) Note: Federal Agencies are NOT eligible
	□		Let’s Move Cities and Towns
	□		Schools (K-12)
4. Public Sector Innovations: If “public sector” was selected in Question 3 as a primary or secondary award category, please indicate the level.
		□	Local
		□	State/territorial
		□	Tribal
5. Health Promotion Areas: Please identify which health promotion areas the innovation addresses. Check all that apply
		□	Healthy Weight
		□	Physical Activity
		□	Nutrition
6. Target Audience: Please Identify/Describe the innovation’s target audience and the geographic area in which the innovation is being implemented. Maximum length is 200 words.
7. Program Participation
7a. Number of Program Participants
7b. Explain how program participation was defined and/or calculated. Maximum length is 100 words.
8. ORGANIZATON Narrative/Summary: Please provide a narrative/summary of the lead ORGANIZATION for the innovation. Maximum length is 200 words.
9. PROGRAM Narrative/Summary: Please provide a narrative/summary of the innovation that includes the rationale (context and need) for the innovation. Be sure to include any objective data or results. Maximum length is 600 words.
10. SELECTION CRITERIA a. Creativity and Innovation Leadership Sustainability Replicability Results/Outcomes Note: You must provide an answer to each of the selection criteria listed below.
10a. Creativity and Innovation: Describe how the innovation exhibits originality, ingenuity, and resourcefulness in addressing the health promotion areas specified. Maximum length is 200 words.
10b. Leadership: Describe how the innovation design and implementation provides direction or guidance that other organizations can emulate to address the same or similar health promotion areas. In addition, please include a description of how the innovation and its leaders actively encourage other organizations/agencies to engage in complementary or similar initiatives to address health promotion areas indicated. Maximum length is 200 words.
10c. Sustainability: Describe the resources and support available for the innovation. Indicate the duration/framework that the innovation is scheduled to run. Also, include information on capacity-building and functioning relationships with other entities (e.g., individuals, organizations, communities, municipalities, and service providers) that have a vested interest in the continuation of the innovation. Characteristics of sustainability may include: a comprehensive plan and timeline for institutionalizing activities; high-quality programming with evaluated and documented success; strong administrative support and involvement of an advisory board; meeting the current funder’s priorities and looking beyond current grants to identify other potential funding sources or non-traditional sources of financial support; and following sound business practices. Maximum length is 200 words.
10d. Replicability: Describe how the innovation has the potential to be effectively duplicated, transferred, or adapted by institutions/organizations with similar competencies and for target populations with similar demographic profiles. Maximum length is 200 words.
10e. Results: What measures were developed to evaluate the performance of this innovation? For example: audience reach, donated media, participation, health outcomes—health improvement, risk reduction, changes in biometric (e.g., BMI), behavior change, and financial outcomes—cost savings, cost-effectiveness, cost-benefit, return on investment. If “other,” please specify. (Note: submissions under the Lets Move Cities and Towns category only need to specify measures developed to evaluate the performance of the innovation if results have not been collected.) Quantifiable data is preferred.
11. Please submit a picture depicting your organization and the innovation being nominated here.
Thank you for submitting a nomination.

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