Form EPA Form 9600-04 EPA Form 9600-04 Design for the Environment Safer Product Labeling Progra

EPA ICR No. 2450.01; OMB Control No. 2070-NEW

ATTACHMENT B

Design for the Environment Safer Product Labeling Program

Partner of the Year Application Form

D esign for the Environment (DfE)

Safer Product Labeling Program Partner of the Year Awards

Instructions for Application Form

EPA developed The Partner of the Year Awards to recognize DfE stakeholders who have furthered the safer chemistry goals of the DfE Safer Product Labeling Program through their active and exemplary participation in and promotion of the program. Making DfE’s mission known to the widest possible audience, through its safer product label and in other forms of communication, is critical to fully realizing the program’s goals of protecting human health and the environment, promoting a sustainable economy, and creating green jobs, especially in the small business sector. DfE anticipates that selecting the Partner of the Year will be a challenging task. Applicants with outstanding applications that do not win the Partner award may receive an honorable mention.

The Partner of the Year Awards will be an annual event, with recognition for DfE stakeholder organizations from five broad categories: (1) Formulators/Product Manufacturers (of both consumer and Institutional/Industrial (I/I) products), (2) Purchasers and Distributors, (3) Retailers, (4) Supporters (e.g., non-governmental organizations, including environmental and health advocates, trade associations, academia, sports teams, and others), and (5) Innovators (e.g., chemical manufacturers, technology developers, and others). Within these categories, DfE may elect to give an additional award in the subcategories of “small business” and “sustained excellence.” Organizations that wish to apply in more than one award category must complete individual application packages.

To be eligible for recognition, candidates should complete this application and have it signed by an appropriate company or organization official (e.g., CEO, vice president for governmental affairs, division head, or other authorized signatory).

EPA reserves the right to request at any time additional documentation to confirm that candidates have achieved the criteria for recognition. If documentation is requested but not received within a reasonable time (e.g., X days), EPA may deny or withdraw recognition.

Application Process: The application is available online and may be filled out and submitted in hard copy by mail, faxed, or scanned and emailed to [email protected]. All applications received will be considered public information and no materials submitted will be returned. If you choose to send the application electronically, the application and signed signature page must be scanned and sent to DfEPartne[email protected].

To be eligible for the awards, which may be announced as soon as Fall 2013, candidates would need to submit their application by Summer 2013 [date to be determined].

Supplemental documents such as photos, pamphlets, copies of advertisements, videos, audio files, etc. may be sent with your application as PDF files (each file must be less than 12MB). If necessary, you can mail hard copies of supplemental material to the following address maintained by our contractor (EPA Contract No. XXXXXXXXX):

Design for the Environment

Safer Product Labeling Program

Partner of the Year Awards

c/o Abt Associates Inc.

Attn: Aviva Loew

4550 Montgomery Avenue, Suite 800 North

Bethesda, MD 20814-5341

P: 301-347-5517

F: 617-386-8090

Confirmation of Receipt: You will receive an email within one week confirming any materials you submit. It will be sent to the Primary Communications contact in the award application. If you do not receive confirmation within one week, please contact the DfE Partner Awards lead, Bridget Williams, at [email protected] or 202-564-8558.

Notification: You may be notified as soon as early Fall 2013 of the status of your application.

Questions: Questions about eligibility, nomination procedures, or Design for the Environment should be directed to Bridget Williams of EPA’s Design for the Environment Program at [email protected] or 202-564-8558.

Paperwork Burden Estimate

The public reporting and recordkeeping burden for this collection of information is estimated to average 15 hours per response, including the time for reviewing instructions, gathering information, and reviewing and completing the application. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this collection is 2070-xxxx. Approval expires on DATE.

Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed application to this address.

Design for Environment

SECTION 1a: Enter requested information for the authorized representative	Organization Name
	Contact Name
	Address
	City, State, Zip
	Phone		Fax
	Email
	Website
SECTION 1b: Indicate your type of organization		Formulators/Product Manufacturers – both Consumer and Industrial/Institutional (Complete items 1-5 in Section 2)
		Purchasers and Distributors (Complete items 3-5 in Section 2)
		Retailers (Complete items 3-5 in Section 2)
		Supporters – e.g. non-governmental organizations, including environmental and health advocates, trade associations, academia, sports teams, and others who promote DfE and the development and use of safer product formulations (Complete items 3-5 in Section 2)
		Innovators – e.g., chemical manufacturers, technology developers, and others who create innovative ways to advance the goals of the DfE Safer Product Labeling Program (Complete items 4-5 in Section 2)
SECTION 1c: Indicate whether your organization is a small business.2 SECTION 1d: Indicate whether your organization should be considered for “sustained excellence.”3		Yes
		No
		Yes
		No

² To qualify as a small business, your business must meet the criteria in the Regulatory Flexibility Act / Small Business Regulatory Enforcement Fairness Act (RFA/SBREFA). For more information, please visit the RFA/SBREFA website at http://www.epa.gov/sbrefa/

³ Those who have been promoting DfE for several years or more would be considered eligible candidates.

SECTION 2:

As part of its environmental mission, the DfE Safer Product Labeling Program partners with businesses and others to reduce health and environmental risks by advancing the manufacture and use of safer products and technologies. Toward this end, DfE increases awareness of the toxicological properties of chemicals through the replacement of chemicals of potential concern with safer alternatives. DfE allows the use of its label on products that perform well and contain the safest possible ingredients, as determined by expert evaluation of the best available science. DfE recognition represents the highest level of achievement in formulating products that are safer for families and the environment.

Making DfE’s mission known to the widest possible audience is key to fully realizing the program’s goals and potential. The purpose of the Partner of the Year award is to recognize stakeholders who have made exceptional contributions to advancing DfE’s mission.

Evaluation criteria:

Criteria for evaluating applications for this award are listed below. In addition, each applicant will be screened to determine their history of civil or criminal EPA enforcement actions. Results of this screening will be factored into the winner selection process.

Please describe your company’s or organization’s activities and accomplishments in furthering DfE’s mission. Your narrative should:

• Be no more than three pages, but may be accompanied by samples of specific promotions, advertisements, or other activities your organization has engaged in.

• Describe your company’s or organization’s recent activities and accomplishments in as much detail as possible.

• Cumulative accomplishment statements may be included in the Accomplishments Narrative, but data specific to the past year’s activities must be highlighted. When discussing cumulative accomplishments, ensure that you include a time frame (e.g., reduced the use of chemicals of concern by 100,000 pounds in 2011, and more than 3,000,000 pounds since 2003).

• Use the information elements listed in the table below to guide development of your narrative.

Tips for Success:

There are a few steps you can take to ensure a successful application.

• Partner of the Year Awards are based on activities that increase awareness of the DfE Safer Product Labeling Program, DfE-labeled products, and the program’s mission to help safeguard human and environmental health through safer chemistry. While general education on the importance of safer chemicals is valued, your application should focus on your specific activities and accomplishments to promote the use of DfE-labeled products and your actions to advance the program.

• Be sure to provide measurable results in your written statement—e.g., number of DfE - labeled products sold, people reached, advertisements run, signs posted, newsletters distributed, etc.

In your Accomplishments Narrative, address the questions appropriate to your organization type:
Formulators/Product Manufacturers0 Complete items 1-5 Weighting percents per item: 20 30 30 10 10		1. Participation in the DfE Safer Product Labeling Program (Applicants must address each of the following items.) Number of DfE-labeled products and percentage change over previous year. Percentage of product line that is DfE-labeled and percentage change over previous year. Percentage of total sales that were DfE-labeled and percentage change over previous year. Information on leadership in DfE-labeled products, including a brief description of any safer chemistry innovations in the product design (e.g., use of a green-chemistry-award-winning ingredient or chemistry that furthers other environmental goals like energy efficiency). 2. Use of the DfE Label Confirm that the DfE label is used appropriately on products, packaging, website and other materials (N.B., the label must appear with the DfE tag line and web address. Consult the DfE Labeling Guide for guidance on proper label use.) Indicate the percentage of DfE - recognized products that carry the DfE label and the location of the label on containers (front, back or cap). Provide information on labeling that goes beyond the basic requirements; prominent use of the label on products or packaging is highly desired, e.g., eye-catching placement on the front of containers. Provide examples or pictures to illustrate DfE label use. 3. Promotion and Use of DfE-labeled Products Describe your efforts to promote or use DfE-labeled products; examples include: featuring DfE in exhibits at industry tradeshows, presentations and other communications; using DfE-labeled products to clean homes, stores and facilities; and, advocating for use of labeled products. Indicate if you have led or participated in cooperative promotions of the DfE label, such as in-store or web-based notices or advertising. For each significant promotion or use, include information on the role of participants and the duration, reach, and outcomes; promotion of the label in mass media, e.g., TV commercials, is highly valued or at major sporting or other events with media coverage. Submit examples of print, radio, television, or direct-mail advertising, as appropriate. 4. Communications on DfE to Consumers and End-Users Describe your DfE-themed outreach or advocacy activities and messaging; for example, public relations efforts, testimony at government hearings, special events, press releases, etc. Submit noteworthy examples of outreach and advocacy efforts; for example, innovative use of the DfE label and messaging on your organization’s website; brochures or other media with DfE messages and label; development of technology or a computer application that educates the public on and promotes the use of safer products. Include information on audience, frequency, and reach, and pictorial examples like Web shots or ads. 5. Innovations in Safer Chemistry and Other Efforts to Advance DfE and Environmental Protection Describe your efforts/successes in developing safer chemicals for use in DfE-labeled products (include number of chemicals in CleanGredients database or used in DfE-labeled products). Discuss your leadership of or participation in activities related to new or existing DfE projects (beyond safer product labeling). Provide examples of your organization’s commitment to chemical-risk-reduction activities or other environmental and health protection/stewardship initiatives. For example, to what extent have you used chemicals listed in CleanGredients in your non-DfE-labeled products? or, what activities illustrate your commitment to sustainable operations?
Purchasers and Distributors; Retailers Complete items 3-5 Weighting percents per item: 3. 40 4. 40 5. 20
Supporters; Innovators Complete items 4-5 Weighting percents per item: Supporters 4. 75 5. 25 Innovators 4. 25 5. 75
SECTION 3: Certification of Application	Please have the appropriate company or organization official (e.g., CEO, vice president for governmental affairs, division head, or other authorized signatory) sign here to verify the accuracy of the application.
		Signature of Authorizing Entity	Date
		Printed Name and Title	Date

I hereby affirm that the contents of this application are true and accurate to the best of my knowledge, and that I am a representative of the company or organization named above and am duly authorized to sign on its behalf.

0 All current DfE Partners may apply. Please note that to be eligible for the Partner of the Year award, partners must be in compliance with all applicable requirements in the DfE Partnership Agreement.