#0693-0006-MBNQA-Eligibility-Instrument-WithTrackedChanges

2017

website

This document contains the Eligibility Certification Form and
checklist for the 2013 Malcolm Baldrige National Quality Award.
Before filling out the form, please see Is Your Organization
Eligible? (http://www.nist.gov/baldrige/enter/eligible.cfm) on our
Web site.
The form uses text fields (
) that expand as you type. To enter
text, place your cursor in the field, click to highlight the field, and
begin typing. Use the Tab key to navigate to the next field.

In addition to the general eligibility conditions and eligibility category requirements detailed on our Web site (see Is Your
Organization Eligible? (http://www.nist.gov/baldrige/enter/eligible.cfm), your organization must meet ONE of the criteria
following
will beplease
moved
listed below to apply for the Baldrige Award.The
If you
have questions,
callto(877) 237-9064, option 3.

inside the tool. It will become

If using criteria 2, 3, or 4, please fill in the information
requested
below.
question 6K
so that
applicants don't

.

miss it.
1. My organization has won the Baldrige
Yes
Award.

No
Your organization is
eligible (five-year rule as
stated on page 7 is still in
effect). for how/why this
See Word document

Continue with
statement 2.

text has
been Your
updated
based is
on a
2. Between 2008 and 2012, my
Yes
organization
No
change in eligibility
rules asked for by
organization received the top award from
eligible.
an award program that is a member of the
the Federal advisory body, the
Award program:
Alliance for Performance Excellence. Baldrige Board of Overseers. The
Year
of topeligibility
award: to
change in rules
opens

Continue with
statement 3.

more organizations,
including isvery
Yes
Your organization
3. Between 2008 and 2012, my
No
and manufacturers
eligible.
organization applied for the national small businesses
Baldrige Award, and the total of the that span states and their subunits.
Year:
process and results band numbers assigned
Total of band scores:
in the feedback report was 8 or higher.

Continue with
statement 4.

4. Between 2008 and 2012, my
organization applied for the national
Baldrige Award and received a site visit.

Yes

No

Continue with
statement 5.

5. More than 25% of my organization's
workforce is located outside the
organization's home state.

Yes

Your organization is
eligible.

No

Continue with
statement 6.

6. There is no Alliance for Performance
Excellence award program available for
my organization.

Yes

Your organization is
eligible.

No

Call 877-2379064, option 3.

Your organization is
eligible.
Year of site visit:

Move notwithstanding statement here. Add above
statement: OMB Clearance #0693-0006
Expiration Date: May 31, 2016

2017

May 31, 2016

2013 Eligibility Certification Form

Page E-1 of 9

OMB Clearance #0693-0006
Expiration Date: March 13, 2013

Malcolm Baldrige National Quality Award
1. Your Organization
Headquarters
address

Official name
Other name
Prior name

(if changed within the past 5 years)

2. Highest-Ranking Official
Mr.

Mrs.

Ms.

Dr.

Name

Address

Same as above

Job title
E-mail
Telephone
Fax

3. Eligibility Contact Point
Designate a person who can answer inquiries about your organization. Questions from your organization and
requests from the Baldrige Program will be limited to this person and the alternate identified below.
Mr.

Mrs.

Ms.

Dr.

Name

Address

Same as above

Job title
E-mail
Telephone

Overnight
mailing
address

Fax

Same as above (Do not use a P.O. box
number.)

4. Alternate Eligibility Contact Point
Mr.
Name
E-mail

Mrs.

Ms.

Dr.
Telephone
Fax

this text not needed here,
nominations are explained in
question 14

All 2017 due
dates TBD
Eligibility package due April 2, 2013 (February 19 if you nominate an examiner)
Award package due May 14, 2013 (April 30 on CD only)

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2013 Eligibility Certification Form

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5. Application History
a. Has your organization previously submitted an eligibility certification package?
Yes. Indicate the year(s). Also indicate the organization’s name at that time, if different.
Year(s)
Name(s)
No

2011

Don’t know

This is no longer
optional due to new
Yes. rules.
Did your
organization receive the award in 2007 or earlier?
eligibility
See
new question
6K.Your organization is eligible to apply for the award.
Yes.

b. Has your organization ever received the Malcolm Baldrige National Quality Award?

No

2012/2016
regional/state/local

No. If your organization received an award between 2008 and 2012, it is eligible to or
apply
for feedback
sector-specific
only. Contact the Baldrige Program at (877) 237-9064, option 3, if you have questions.
(for clarity)

c. (Optional; for statistical purposes only) Has your organization participated in a state or local Baldrige-based
award process?
Yes. Years:
No

this text now in
new question 6K

7.
6. Award Category

See Is Your Organization Eligible? (http://www.nist.gov/baldrige/enter/eligible.cfm) on our Web site.
a. Award category (Check one.)
Your education or health care organization may use the Business/Nonprofit Criteria and apply in the service,
small business, or nonprofit category. However, you probably will find the sector-specific Criteria more
appropriate.
For-Profit

Nonprofit

Manufacturing

Nonprofit

Service

Education

Small business (≤ 500 employees)

Health care

Education
Health care

add for clarity:
(Education or
Health Care)

Add: In table
below, list

b. Industrial classifications. List up to three of the most descriptive NAICS codes for your organization (see NAICS
list included at the end of this document). These are used to identify your organizational functions and to assign
applications to examiners.

If you are unable to respond to any item,
call (877) 237-9064, option 3, before submitting this form.

2017

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7. Organizational Structure
8.
a. For the preceding fiscal year, the organization had

in

up to $1 million

$1.1 million–$10 million

sales

$10.1 million–$100 million

$100.1 million –$500 million

revenue

$500.1 million–$1 billion

more than $1 billion

budget

b. Attach a line-and-box organization chart that includes divisions or unit levels. In each box, include the name of
Change
text for
the unit or division and the name of its leader. Do not
use shading
or color in the boxes.

clarity: See item 6
above.

The chart is attached.

c. The organization is _____ a larger parent or system. (Check all that apply.)
not a subunit of (Proceed to item 8.)
a subsidiary of

controlled by

administered by

owned by

a division of

a unit of

a school of

other __

Parent organization

___

Address

Total number of paid
employees*

Delete. Baldrige
Board of Overseers
changed rule
Telep one
regarding subunits
*Paid employees include permanent, part-time, temporary, and telecommuting
so that moreemployees,
would as well as
contract employees supervised by the organization. Include employees
of
subunits
but not those of joint
be eligible.
Highest-ranking official

Job title

ventures.

d. Is your organization the only subunit of the parent intending to apply for the award? Based on the parent
organization’s size, the program may accept multiple applications within or across award categories from
subunits (see Is Your Organization Eligible? (http://www.nist.gov/baldrige/enter/eligible.cfm).
Yes

No (Briefly explain below.) 

Don’t know

e. Attach a line-and-box organization chart(s) showing your organization’s relationship to the parent’s highest
management level, including all intervening levels. In each box, include the name of the unit or division and its
leader. Do not use shading or color in the boxes.
The chart is attached.

d.f. Considering the organization chart, briefly describe below how your organization relates to the parent and its
other subunits in terms of products, services, and management structure.

All 2017
dates are
TBD

Eligibility package due April 2, 2013 (February 19 if you nominate an examiner)
Award package due May 14, 2013 (April 30 on CD only)

2017

2013 Eligibility Certification Form

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e.g. Provide the title and date of an official document (e.g., an annual report, organizational literature, a press
release) that clearly defines your organization as a discrete entity.
Title

website

Date

Attach a copy of relevant portions of the document. If you name a Web site as documentation, print and attach
the relevant pages, providing the name only (not the URL) of the Web site.
Relevant portions of the document are attached.
h. Briefly describe the major functions your parent or its other subunits provide to your organization, if
appropriate. Examples are strategic planning, business acquisition, research and development, facilities
management, data gathering and analysis, human resource services, legal services, finance or accounting,
sales/marketing, supply chain management, global expansion, information and knowledge management,
education/training programs, information systems and technology services, curriculum and instruction, and
academic program coordination/development.

6.8. Eligibility Determination
See also Is Your Organization Eligible? (http://www.nist.gov/baldrige/enter/eligible.cfm).
a. Is your organization a distinct organization or business unit headquartered in the United States?
Yes

No Briefly explain.

1, 2016
b. Has your organization officially or legally existed for at least one year, or since April 2, 2012?
Yes

No

c. Can your organization respond to all seven Baldrige Criteria categories? Specifically, does your organization have
processes and related results for its unique operations, products, and/or services? For example, does it have an
independent leadership system to set and deploy its vision, values, strategy, and action plans? Does it have
approaches for engaging customers and the workforce, as well as for tracking and using data on the effectiveness
of these approaches?
Yes

add: or its
No
territories

d. If some of your organization’s activities are performed outside the United States or its territories and your
organization receives a site visit, will you make available sufficient personnel, documentation, and facilities in the
United States to allow a full examination of your worldwide organization?
Yes

No

Not applicable
©

e. If your organization receives an award, can it make sufficient personnel and documentation available to share its
practices at The Quest for Excellence Conference and at your organization’s U.S. facilities?
Yes

No

6c,8d,
6d,oror
If you checked “No” for6a,
8a, 6b,
8b, 8c,
8e,6e
call the Baldrige Program at (877) 237-9064, option 3.
If you are unable to respond to any item,
call (877) 237-9064, option 3, before submitting this form.

2017

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Questions for Subunits Only

f.

Is your subunit recognizably different from the parent and its other subunits? For example, do your customers
distinguish your products and services from those of the parent and/or other subunits? Are your products or services
unique within the parent? Do other units within the parent provide the same products or services to a different
customer base?
Yes. Continue with 8g.
No. Your subunit probably is not eligible to apply for the award. Call the Baldrige Program at (877) 237-9064,
option 3.

f. g. Is your organization a subunit in education or health care? (Check your eligibility by reading Is Your Organization
Eligible? (http://www.nist.gov/baldrige/enter/eligible.cfm) on our Web site.)
Yes. Proceed to item 9.
No. Continue with 8h.
6g.
h. Does your subunit have more than 500 paid employees?

Add: Then proceed
to item 6k.

See new 6h in
Yes. Your organization is eligible to apply for the award. Proceed to item 9.
Word file.
No. Continue with 8i.

i.

Is your subunit in manufacturing or service?
Yes. Is it separately incorporated and distinct from the parent’s other subunits? Or was it independent before being
acquired by the parent, and does it continue to operate independently under its own identity?

See new 6i in

Yes. Your
subunit
Word
file.is eligible in the small business category. Attach relevant portions of a supporting official
document (e.g., articles of incorporation) to this form. Proceed to item 9.
No. Continue with 8j.
No. Your subunit probably is not eligible to apply for the award. Call the Baldrige Program at (877) 237-9064,
option 3.
j.

See new 6j in Word

Does your subunit (1) have more than 25 percent of the parent’s employees, and (2) does your subunit sell or provide
file. to customers/users outside your subunit, its parent, and other
50 percent or more of its products or services directly
organizations that own or have financial or organizational control of your subunit or the parent?
Yes. Your organization is eligible to apply for the award.
No. Your organization probably is not eligible to apply for the award. Call the Baldrige Program at (877) 2379064, option 3.

9. Supplemental Sections
The organization has (a) a single performance system that supports all of its product and/or service lines and (b)
products or services that are essentially similar in terms of customers/users, technology, workforce or employee types,
and planning.
Yes. Proceed to item 10.
No. Your organization may need to submit one or more supplemental sections with its application. Call the
Baldrige Program at (877) 237-9064, option 3.

All 2017 dates
are TBD

Eligibility package due April 2, 2013 (February 19 if you nominate an examiner)
Award package due May 14, 2013 (April 30 on CD only)

2017

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2017

10. Application Format

If your organization
applies for the 2013 award, in which format will you submit your application?
25
15 paper copies and a CD (must be postmarked on or before May 14, 2013)
CD only (must be postmarked on or before April 30, 2013)

2017
Dates
TBD

11. Use of Cell Phones, Cordless Phones, and Voice-over-Internet Protocol (VoIP)
Do you authorize Baldrige examiners to use cell phones, cordless phones, and VoIP to discuss your application? Your
answer will not affect your organization’s eligibility. Examiners will hold all your information in strict confidence
and will discuss your application only with other assigned examiners and with Baldrige Program representatives as
needed.
Yes

No

See struck-out
text rewritten for
12. Site Listing
clarity in Word
You may attach or continue your site listing on a separate page as long as you include all the information
file. requested
here. You may group sites by function or location (city, state), as appropriate. Please include the total for each
column (sites, employees/faculty/staff, and volunteers). If your organization receives a site visit, the Baldrige
Program will request a more detailed listing. Although site visits are not conducted at facilities outside the United
States or its territories, these facilities may be contacted by teleconference or videoconference.
Example

List the % at each site, or
use “N/A” (not applicable).

Workforce*

List the numbers at each site.
Example reworked to represent health Check one or more.

care, as that sector has the most
applicants.
See
Word
file.
Sites
(U.S.
and Foreign)
List the city and the state or country.
Coyote Hall
Albuquerque, NM
Cactus Hall
Bernalillo, NM

Total

 Employees
 Faculty
 Staff
381 Faculty
200 Staff
17 Faculty
2 Staff

2

600

% of
Volunteers
(or  N/A)

Check one.
 Sales
 Revenue
 Budget

25

95%

3

5%
28

100%

*The term “workforce” refers to all people actively involved in accomplishing the work of your organization, including
paid employees (e.g., permanent, part-time, temporary, and telecommuting employees, as well as contract employees
supervised by the organization) and volunteers, as appropriate. The workforce includes team leaders, supervisors, and
managers at all levels.
Add column for
Your Organization
Workforce*

Sites (U.S. and Foreign)

List the city and the state or country.

"Relevant Products,
Services, and/or
List the % at each site, or
Technology"

List the numbers at each site.
change to: no. or
Check one or more.
(edit for clarity)
Employees
Volunteers
Faculty
(or
Staff
N/A)

If you are unable to respond to any item,
call (877) 237-9064, option 3, before submitting this form.

use “N/A” (not applicable).
Check one.
% of
Sales
Revenue
Budget

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. The workforce
includes

, and contract
Total

100%

*The term “workforce” refers to all people actively involved in accomplishing the work of your organization, including
paid employees (e.g., permanent, part-time, temporary, and telecommuting employees, as well as contract employees
supervised by the organization) and volunteers, as appropriate. The workforce includes team leaders, supervisors, and
managers at all levels.
; it also
where necessary
Add text: (we
recommend using
13. Key Business/Organization Factors
bullets)
List or briefly describe the following key business/organization factors. Please be concise, but be as specific as
possible. Provide full names of organizations (i.e., do not use acronyms). The Baldrige Program uses this information
to avoid conflicts of interest when assigning examiners to your application. Examiners also use this information in
their evaluations.
a. Main products and/or services and major markets served (local, regional, national, and international)

b. Key competitors (those that constitute 5 percent or more of your competitors)

c. Key customers/users (those that constitute 5 percent or more of your customers/users)

d. Key suppliers/partners (those that constitute 5 percent or more of your suppliers/partners)

e. Financial auditor

f.

Fiscal year (e.g., October 1–September 30)

Add: f. Parent organization (if your organization is a subunit).

All 2017
due dates
TBD

Eligibility package due April 2, 2013 (February 19 if you nominate an examiner)
Award package due May 14, 2013 (April 30 on CD only)

2017

2013 Eligibility Certification Form

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14. Nomination to the Board of Examiners
If you submit your eligibility certification package on or before February 19, 2013, you may nominate one senior
member from your organization to the 2013 Board of Examiners.
Nominees are appointed for one year only. Nominees

See text in Word file
rewritten for clarity.



must not have served previously on the Board of Examiners and



must be citizens of the United States, be located in the United States or its territories, and be employees of
the applicant organization.

The program limits the number of examiners from any one organization. If your organization already has
representatives on the board, nominating an additional person may affect their reappointment.
Board appointments provide a significant opportunity for your organization to learn about the Criteria and the
evaluation process. The time commitment is also substantial: examiners commit to a minimum of 110 hours from
April to December, including approximately 40 hours in April/May to complete self-study, three to four days in May
to attend Examiner Preparation, and 50–70 hours from June through August to complete an Independent and
Consensus Review. If requested by the program, examiners also participate in a Site Visit Review of approximately
nine days. The nominee or the organization must cover travel and housing expenses incurred for Examiner
Preparation.
Mr.

Mrs.

Ms.

2017

Dr.

from our organization will serve on the 2013 Board of Examiners.
E-mail address
I understand that the nominee or the organization will cover travel and hotel costs associated with participation in
Examiner Preparation. See Word file for added

sentence.

If you are unable to respond to any item,
call (877) 237-9064, option 3, before submitting this form.

2017

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15. Fee
Indicate your method of payment for the $360 eligibility certification fee.
Check (enclosed)

Money order (enclosed) Make payable to the Malcolm Baldrige National Quality Award.

ACH payment

Wire transfer

Checking ABA routing number: 075-000-022
Checking account number: 182322730397

Before sending an ACH payment or wire transfer, notify the American Society for Quality (ASQ; [414] 298-8789, ext.
7205, or [email protected]). Reference the Baldrige Award with your payment.
Visa

MasterCard

American Express

Card number

Authorized signature

Expiration date

Printed name

Card billing address

Today’s date

W-9 Request

If you require an IRS Form W-9 (Request for Taxpayer Identification Number and Certification), contact ASQ at
(414) 298-8789, ext. 7205.
16. Self-Certification and Signature
I state and attest the following:
(1) I have reviewed the information provided in this eligibility certification package.
(2) To the best of my knowledge,
 this package includes no untrue statement of a material fact, and
 no material fact has been omitted.

2017

(3) Based on the information herein and the current eligibility requirements for the Malcolm Baldrige National
Quality Award, my organization is eligible to apply.
(4) I understand that if the information is found not to support eligibility at any time during the 2013 award process,
my organization will no longer receive consideration for the award and will receive only a feedback report.

Signature of highest-ranking official
17. Submission

2017

Printed name

Date

postmarked no
later than [insert
date], to

To be considered for the 2013 award, submit your eligibility certification package
 on or before February 19, 2013, if you include a nomination to the Board of Examiners
 on or before April 2, 2013, without a nomination, to
Malcolm Baldrige National Quality Award
c/o ASQ—Baldrige Award Administration
600 North Plankinton Avenue
Milwaukee, WI 53203
(414) 298-8789, ext. 7205

Include proof of the mailing date. Send the package via
 a delivery service (e.g., Airborne Express, Federal Express, United Parcel Service, or the United States Postal
Service [USPS] Express Mail) that automatically records the mailing date or
 the USPS (other than Express Mail), with a dated receipt from the post office.
Eligibility package due April 2, 2013 (February 19 if you nominate an examiner)
Award package due May 14, 2013 (April 30 on CD only)

All dates
TBD

Add header for this page: 2017 Eligibility Certification Form Checklist

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1. Eligibility Certification Form*
I have answered all questions completely.
I have included a line-and-box organization chart showing all components of the organization and the name of
each unit or division and its leader.
Insert text

regarding new
eligibility rule. See
Word file.

The highest-ranking official has signed the form.
For Subunits Only

I have included a line-and-box organization chart(s) showing the subunit’s relationship to the parent’s highest
management level, including all intervening levels.
I have enclosed copies of relevant portions of an official document clearly defining the subunit as a discrete
entity.
*Please do not staple the pages of this form.
2. Fee
I have indicated my method of payment for the nonrefundable $360 eligibility certification fee.
If paying by check or money order, I have made it payable to the Malcolm Baldrige National Quality Award
and included it in the eligibility certification package.
3. Submission and Examiner Nomination

2017

I am nominating a senior member of my organization to the 2013 Board of Examiners, and I am submitting the
eligibility certification package on or before February 19, 2013.
I am not nominating a senior member of my organization to the 2013 Board of Examiners, and I am submitting
the eligibility certification package on or before April 2, 2013.
I have included proof of the mailing date. (See page E-8.)
I am sending the complete eligibility certification package to

See Word file for
sentence added.

Malcolm Baldrige National Quality Award
c/o ASQ—Baldrige Award Administration
600 North Plankinton Avenue
Milwaukee, WI 53203
(414) 298-8789, ext. 7205

All dates TBD
Eligibility package due April 2, 2013 (February 19 if you nominate an examiner)
Award package due May 14, 2013 (April 30 on CD only)

2013 Eligibility Certification Form

Page E-2 of 9

North American Industry Classification System (NAICS) Codes
Please insert NAICS codes most relevant to your organization’s products and/or services in the Eligibility Certification
Form. For more information about the NAICS codes, go to http://www.census.gov/eos/www/naics/.
Code Sector
111 Crop Production
112 Animal Production
113 Forestry and Logging
114 Fishing, Hunting and Trapping
115 Support Activities for Agriculture and Forestry
211 Oil and Gas Extraction
212 Mining (except Oil and Gas)
213 Support Activities for Mining
221 Utilities
233 Building, Developing and General Contracting
234 Heavy Construction
235 Special Trade Contractors
238 Specialty Trade Contractors
311 Food Manufacturing
312 Beverage and Tobacco Product Manufacturing
313 Textile Mills
314 Textile Product Mills
315 Apparel Manufacturing
316 Leather and Allied Product Manufacturing
321 Wood Product Manufacturing
322 Paper Manufacturing
323 Printing and Related Support Activities
324 Petroleum and Coal Products Manufacturing
325 Chemical Manufacturing
326 Plastics and Rubber Products Manufacturing
327 Nonmetallic Mineral Product Manufacturing
331 Primary Metal Manufacturing
332 Fabricated Metal Product Manufacturing
333 Machinery Manufacturing
3331 Agriculture, Construction, and Mining Machinery Manufacturing
3332 Industrial Machinery Manufacturing
3333 Commercial and Service Industry Machinery Manufacturing
3334 Ventilation, Heating, Air-Conditioning and Commercial Equipment Manufacturing
3335 Metalworking Machinery Manufacturing
3336 Engine, Turbine, and Power Transmission Equipment
3339 Other General Purpose Machinery Manufacturing
334 Computer and Electronic Product Manufacturing
3341 Computer and Peripheral Equipment Manufacturing
3342 Communications Equipment Manufacturing
3344 Semiconductor and Other Electronic Component Manufacturing
335 Electrical Equipment, Appliance and Component Manufacturing
3353 Electrical Equipment Manufacturing
3359 Other Electrical Equipment and Component Manufacturing
336 Transportation Equipment Manufacturing
337 Furniture and Related Product Manufacturing
If you are unable to respond to any item,
call (877) 237-9064, option 3, before submitting this form.

339 Miscellaneous Manufacturing
421 Wholesale Trade, Durable Goods
422 Wholesale Trade, Nondurable Goods
423 Merchant Wholesalers, Durable Goods
425 Wholesale Electronic Markets and Agents and Brokers
441 Motor Vehicle and Parts Dealers
442 Furniture and Home Furnishings Stores
443 Electronics and Appliance Stores
444 Building Material and Garden Equipment and Supplies Stores
445 Food and Beverage Stores
446 Health and Personal Care Stores
447 Gasoline Stations
448 Clothing and Clothing Accessories Stores
451 Sporting Goods, Hobby, Book and Music Stores
452 General Merchandise Stores
453 Miscellaneous Store Retailers
454 Nonstore Retailers
481 Air Transportation
482 Rail Transportation
483 Water Transportation
484 Truck Transportation
485 Transit and Ground Passenger Transportation
486 Pipeline Transportation
487 Scenic and Sightseeing Transportation
488 Support Activities for Transportation
491 Postal Service
492 Couriers and Messengers
493 Warehousing and Storage Facilities
511 Publishing Industries
512 Motion Picture and Sound Recording Industries
513 Broadcasting and Telecommunications
514 Information Services and Data Processing Services
517 Telecommunications
521 Monetary Authorities - Central Bank
522 Credit Intermediation and Related Activities
5221 Depository Credit Intermediation
5222 Non-Depository Credit Intermediation
5223 Activities Related to Credit Intermediation
523 Securities, Commodity Contracts and Other Intermediation
5231 Securities and Commodity Contracts Intermediation
5232 Securities and Commodity Exchanges
5239 Other Financial Investment Activities
524 Insurance Carriers and Related Activities
525 Funds, Trusts and Other Financial Vehicles (U.S. Organizations)
5251 Insurance and Employee Benefit Funds
5259 Other Investment Pools and Funds
531 Real Estate
532 Rental and Leasing Services
533 Owners and Lessors of Other Non-Financial Assets
541 Professional, Scientific and Technical Services
551 Management of Companies and Enterprises
561 Administrative and Support Services
562 Waste Management and Remediation Services
Eligibility package due April 2, 2013 (February 19 if you nominate an examiner)
Award package due May 14, 2013 (April 30 on CD only)

all
dates
TBD

2013 Eligibility Certification Form
611 Educational Services
6111 Elementary and Secondary Schools
6112 Junior Colleges
6113 Colleges, Universities, and Professional Schools
6114 Business Schools and Computer and Management Training
6115 Technical and Trade Schools
6116 Other Schools and Instruction
6117 Educational Support Services
621 Ambulatory Health Care Services
6211 Offices of Physicians
6212 Offices of Dentists
6213 Offices of Other Health Practitioners
6214 Outpatient Care Centers
6215 Medical and Diagnostic Laboratories
6216 Home Health Care Services
6219 Other Ambulatory Health Care Services
622 Hospitals
623 Nursing and Residential Care Facilities
624 Social Assistance
711 Performing Arts, Spectator Sports and Related Industries
712 Museums, Historical Sites and Similar Institutions
713 Amusement, Gambling and Recreation Industries
721 Accommodation (hotels)
722 Food Services and Drinking Places
811 Repair and Maintenance
812 Personal and Laundry Services
813 Religious, Grantmaking, Civic, and Professional and Similar Organizations
814 Private Households
921 Executive, Legislative, Public Finance and General
922 Justice, Public Order, and Safety
923 Administration of Human Resource Programs
924 Administration of Environmental Quality Programs
925 Administration of Housing Programs, Urban Planning
926 Administration of Economic Programs
927 Space Research and Technology
928 National Security and International Affairs
999 Unclassified Establishments

If you are unable to respond to any item,
call (877) 237-9064, option 3, before submitting this form.

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Paperwork Reduction Act Statement
Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a
penalty for failure to comply with, a collection of information subject to the requirements of the Paperwork Reduction
Act, unless that collection of information displays a currently valid OMB Control Number.
The reason for collecting this information is toUse
allow
organizations
to apply for the Malcolm Baldrige National Quality
updated
notwithstanding
Award (award). The information obtained will assist in determining the award recipients. Responses to the collection of
statement
information are required for organizations to be considered for the award. Confidentiality of the submitted information is
covered under the Freedom of Information Act to the extent possible under the law.
The public reporting burden for this collection is estimated to average 100 hours for the initial response of the first-time
applicant (this includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the
relevant data, and completing and reviewing the collection of information). As the organization reapplies for the award in
future years, this burden may change, in either direction, based on the feedback the respondent gains from its first
application.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden, to

Robert Fangmeyer

Dr. Harry Hertz, Director
Baldrige Performance Excellence Program
National Institute of Standards and Technology
Administration Building, Room A600
100 Bureau Drive, Stop 1020
Gaithersburg, MD 20899-1020
and to
Office of Information and Regulatory Affairs
Office of Management and Budget
Washington, DC 20503

All dates TBD

Eligibility package due April 2, 2013 (February 19 if you nominate an examiner)
Award package due May 14, 2013 (April 30 on CD only)