FINAL_HCS_SSB_ATTACH 2_NOMINATION FORM_Jan 2013

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Overview

Nomination_Form
Reference

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Sheet 1: Nomination_Form

SSB Attachment 2
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>

Alabama

Alaska

American Samoa

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

District of Columbia

Florida

Georgia

Guam

Hawaii

Idaho

Illinois

Indiana

Iowa

Kentucky

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

North Carolina

North Dakota

Ohio

Oklahoma

Oregon

Pennsylvania

Puerto Rico

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

U.S. Virgin Islands

Utah

Vermont

Virginia

Washington

West Virginia

Wisconsin

Wyoming