Copy of HCS_SSB_ATTACH 1_NOMINATION FORM_SEPTEMBER 2011 FINAL for OMB

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Overview

Nomination_Form
Reference

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Sheet 1: Nomination_Form

SSB Attachment 1
INSTRUCTIONS: Please consider for certainty community nominations those communities that you would characterize as highly active over the past decade (2001 - 2011) in addressing obesity or obesity-related factors (e.g., diet and physical activity) among children and youth. For the purposes of the Healthy Communities Study, a “community” is the geographic equivalent of a public high school catchment area. However, you may nominate communities at different levels of geographic specificity (e.g., city, neighborhood, county). Please provide information about obesity-related programs and/or policies in this community in the appropriate spaces below.
NOMINATED COMMUNITY
1a	Community Name			<Enter text>
1b	How would you characterize this community geographically?					Other:
1c	Community Location: County
1d	Community Location: State/U.S. Territory
1e	Please provide a few sentences about why you believe this community merits inclusion in the HCS			<Enter text>
PROGRAM INFORMATION
INSTRUCTIONS: Please provide the following details about any program(s) addressing obesity or obesity-related factors in the nominated community. If you would like to describe more than 10 programs, please insert additional rows below item "2j".
2	Program Name	Funding Organization/Sponsor	Funding Amount	Duration of Program (including year ended, if applicable)	Geographic Area Targeted by Program (e.g., Entire Community, Other - if Other, please describe)	Links/Public Documents with More Information about Program
2a			<Enter a dollar amount>			<Enter references>
2b			<Enter a dollar amount>			<Enter references>
2c			<Enter a dollar amount>			<Enter references>
2d			<Enter a dollar amount>			<Enter references>
2e			<Enter a dollar amount>			<Enter references>
2f			<Enter a dollar amount>			<Enter references>
2g			<Enter a dollar amount>			<Enter references>
2h			<Enter a dollar amount>			<Enter references>
2i			<Enter a dollar amount>			<Enter references>
2j			<Enter a dollar amount>			<Enter references>
POLICY INFORMATION
INSTRUCTIONS: Please provide the following details about policies addressing obesity or obesity-related factors in the nominated community. If you would like to describe more than 10 policies, please insert additional rows below item "3j".
3	Policy Name	Implementing Organization		Duration of Policy (including year ended, if applicable)	Geographic Area Targeted by Policy (e.g., Entire Community, Other - if Other, please describe)	Links/Public Documents with More Information about Policy
3a						<Enter references>
3b						<Enter references>
3c						<Enter references>
3d						<Enter references>
3e						<Enter references>
3f						<Enter references>
3g						<Enter references>
3h						<Enter references>
3i						<Enter references>
3j						<Enter references>
NOMINATOR CONTACT INFORMATION
4a	Name:
4b	Organization:
4c	Address:
4d	City:
4e	State:
4f	Phone:
4g	Email:

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Sheet 2: Reference

<Select State>

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Tennessee

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Utah

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Washington

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Wisconsin

Wyoming