2017 Nomination Form
National Medal for Museum and Library Service
(To be filled out by the nominated organization.)
A. Cover Sheet
Legal Name of your Organization:1 _________________________________________________________________
Organizational Unit (if different from Legal Name): ____________________________________________________
Organization Address
Street 1: ____________________________ Street 2: ______________________________________
City: _______________________________ County: _______________________________________
State: ______________________________ Zip+4/Postal Code: ______________________________
Telephone Number: ___________________ 4. Fax Number: ___________________________________
Web Address: http://_____________________________________________________________________________
Name of Organization’s Director/CEO: _______________________________________________________________
Title: __________________________________________________________________________________________
E-mail: ______________________________ Telephone Number: ______________________________
Your Name (the person completing this form): _________________________________________________________
Title: ___________________________________________________________________________________________
E-mail: ______________________________ Telephone Number: _______________________________
Type of Organization (check one):
□ Academic Library □ Natural History/Anthropology Museum
□ Aquarium □ Nature Center
□ Arboretum/Botanical Garden □ Planetarium
□ Art Museum □ Public Library
□ Children’s/Youth Museum □ Research Library/Archives
□ Digital Library □ School Library, or School District applying on
behalf of a School Library or Libraries
□ General Museum2 □ Science/Technology Museum
□ Historic House/Site □ Special Library
□ History Museum □ Specialized Museum3
□ Library Association □ Zoo
□ Library Consortium □ Other, please specify: ______________________________
□ Museum Library
A. Cover Sheet (continued)
Governing Control (check one):
□ State Government □ Nonprofit with 501(c)3 IRS Status (Other than Institution
□ County Government of Higher Education)
□ City or Township Government □ Nonprofit without 501(c)3 IRS Status (Other than Institution
□ Special District Government of Higher Education)
□ Regional Organization □ Private Institution of Higher Education
□ U.S. Territory or Possession □ Individual
□ Independent School District □ For-Profit Organization (Other than Small Business)
□ Public/State-Controlled Institution of □ Small Business
Higher Education □ Hispanic Serving Institution
□ Indian/Native American Tribal □ Historically Black Colleges and Universities (HBCUs)
Government (Federally Recognized) □ Tribally Controlled Colleges and Universities (TCCUs)
□ Indian/Native American Tribal □ Alaska Native and Native Hawaiian Serving Institutions
Government (Other than Federally □ Nondomestic (non-U.S.) Entity
Recognized) □ Other, please specify: ______________________________
□ Public/Indian Housing Authority
Nominated Organization’s D-U-N-S® Number:4 ________________________________________________
Nominated Organization’s Employer/Taxpayer Number (EIN/TIN): ________________________________
Congressional District of Nominated Organization:5 ____________________________________________
Organization’s Annual Operating Budget: ____________________________________________________
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Difference between B. Total Revenue and C. Total Expenses |
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If your organization had a deficit greater than 10% of your annual operating budget for any of the fiscal years listed above, please explain the circumstances of this deficit. [Text box]
Has your organization had an A-133 audit in the past three years? Yes; No
If no, has your organization had a financial statement audit in the past three years? Yes; No
Were there any material weaknesses identified in your organization’s prior year’s audit report? Yes; No; Not applicable * A material weakness is a deficiency, or combination of deficiencies, in internal control, such that there is a reasonable possibility that a material misstatement of the entity’s financial statements will not be prevented, or detected and corrected on a timely basis.
If yes, please explain. [Text box]
Number of full-time paid organization staff: _________ Number of part-time paid organization staff: __________
Number of full-time unpaid organization staff Number of part-time unpaid organization staff
(including volunteers): ___________________________ (including volunteers): ____________________________
Total number of days the organization was open to the public for the past 12-month period prior to application: ____
Name of Nominating Individual: _____________________________________________________________________
Title: _________________________________________ Relationship to Organization: _______________________
E-mail: _______________________________________ Telephone Number: _______________________________
In addition to the Cover Sheet (Section A), your submission must include the following parts (Sections B-D below). Do not include additional cover letters, binders, folders, or attachments.
B. Executive Summary and Mission Statement (not to exceed one single-spaced page; no less than 12-point type)
Summarize why you believe your organization deserves to win the National Medal for Museum and Library Service.
Provide your organization’s mission statement or statement of purpose as well as a brief institutional history.
Narrative8 (not to exceed four single-spaced pages; no less than 12-point type)
The National Medals are designed to recognize outstanding libraries and museums that have made significant contributions in service to their communities. Address questions 1-4 thoroughly and succinctly. The jurors considering the pool of potential medal recipients will focus carefully on your answers to these questions.
Describe the community9 and the particular community needs addressed.
Quantify and describe the population groups/communities your organization is reaching through its programs, services, and/or partnerships.
What particular community needs do you address? How did you identify these particular needs? How are these needs incorporated into your strategic plan?
What are your attendance rates: onsite; offsite, and virtually?
Describe the programming your organization has developed for these particular community needs. (see section C.1.)
Please include a brief description of your full portfolio of services, even if you focus on a particular area of service. How do you involve your community in the development of your programs?
How do you involve your community in the development of your programs?
How have these partnerships increased your ability to reach out to the targeted population groups and communities you serve?
Describe how you serve community members with special needs. Please address accessibility for people with disabilities.
Describe what impact your organization’s programs and services have had on the identified community needs.
Do you conduct a formal evaluation of your programs? If so, what have you learned about meeting the needs of your audiences?
If you do not have a formal evaluation of programs, how do you measure success?
How have you used this information to plan future programs and services?
Describe your organization’s financial situation
List your organization’s three primary sources of revenue. Do you have a sustainable funding model that will enable growth?
Describe any private or non-profit groups that support your mission and activities and the extent of their support.
D. Letters of Support (required - three maximum, submitted with the Nomination Form)
These letters should come from community members who have direct knowledge of your organization’s community service. We recommend that the letters come from different segments of the broader community served by the institution and from individuals who have either witnessed or experienced first-hand a particular program or service.
Nomination letters from members of Congress are welcome and will not count against the three-letter maximum.
Address letters to the Director of the Institute of Museum and Library Services and include them with this Nomination Form.
Website – http://www.imls.gov/applicants/detail.aspx?GrantId=13
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Deadline: |
October 3, 2016 |
Program Contact for Museums:
Program Contact for Libraries: |
Mark
Feitl, Museum Program Specialist |
Program Overview:
The National Medal honors outstanding libraries and museums that have made significant and exceptional contributions in service to their communities. Selected institutions demonstrate extraordinary approaches to serving their constituents; they exceed expected levels of community outreach. These organizations have established themselves as community anchor institutions. Recipient institutions are honored at an awards ceremony that is held in Washington, DC.
Nominations should describe the:
population served and community needs;
institution’s programs, services, and partnerships;
impact and evaluation of programs; and
financial sustainability.
How are the recipients of the National Medal selected?
The Director of the Institute of Museum and Library Services, with the advice of the Museum and Library Services Board, selects the recipients of the National Medals. In addition to the Medal, IMLS may grant a monetary award.
When are the recipients of the National Medal announced?
The recipients of the National Medals are usually announced in the spring on the IMLS website and through a press release.
Who is eligible for a National Medal nomination?
For museums:
In general: Aquariums, Arboretums/Botanical Gardens, Art Museums, Children’s/Youth Museums, General Museums, Historic Houses/Sites, History Museums, Natural History/Anthropology Museums, Nature Centers, Planetariums, Science/Technology Centers, Specialized Museums, and Zoos may be nominated for the National Medal for Museum Service if they: are either a unit of State or local
government or a private nonprofit organization that has tax-exempt status under the Internal Revenue Code;
are located in one of the 50 States of the United States of America, the District of Columbia, the Commonwealth of Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, the Commonwealth of the Northern Mariana Islands, the Republic of the Marshall Islands, the Federated States of Micronesia, or the Republic of Palau; and
qualify as:
a museum that, using a professional staff, is organized on a permanent basis for essentially educational or aesthetic purposes; owns or uses tangible objects, either animate or inanimate; cares for these objects; and exhibits these objects to the general public on a regular basis through facilities that it owns or operates.
A public or private nonprofit agency which is responsible for the operation of a museum may apply on behalf of the museum.
For libraries:
In general: Academic Libraries, Digital Libraries, Library Associations, Library Consortia, Public Libraries, Research Libraries/Archives that make information available to the public and that are not an integral part of an institution of higher learning, Public School Libraries, and Private or Special Libraries that are considered libraries as determined by the State in which they are located, may be nominated for the National Medal for Library Service. They should also be: either a unit of State or local government or be a private nonprofit organization that has tax-exempt status under the Internal Revenue Code; and
located in one of the 50 States of the United States of America, the District of Columbia, the Commonwealth of Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, the Commonwealth of the Northern Mariana Islands, the Republic of the Marshall Islands, the Federated States of Micronesia, or the Republic of Palau.
Previous library or museum medal recipients may reapply after ten years.
Who may nominate a library or museum for the National Medal?
Anyone, including the institution’s employees, board members, members of its community, and elected officials, may nominate a museum or library for this honor.
What steps should nominators take?
If an institution self-nominates, it simply needs to submit the nomination materials to IMLS by the deadline.
If someone outside of the institution wants to make a nomination, they should notify the museum or library directly and ask them to complete and submit the nomination form in advance of the deadline.
What information is necessary in order for an institution to be considered for the National Medal and who is responsible for providing it?
Your institution, not the individual who nominates it, must complete the Nomination Form and include the following four parts:
A. Cover Sheet
B. Executive Summary & Mission Statement
C. Narrative (four questions)
D. Letters of Support
Do not include additional cover letters, binders, folders, or attachments. For detailed information on answering parts B-D, refer to the Nomination Form.
What is the deadline for submitting the Nomination Form?
The Nomination Form and letters of support should be sent by October 3, 2016, to this email address: [email protected]
Alternatively, nominations may be mailed and postmarked by October 3, 2016, to this address:
The National Medal for Museum and Library Service
Office of the Director
Institute of Museum and Library Services
955 L’Enfant Plaza North, SW, Suite 4000
Washington, D.C. 20024-2135
1 If your organization is not an eligible entity on its own, then enter the name and address of the eligible entity under “Legal Name.” For example, if a library that is part of a parent organization such as a university is applying, it would enter the university under “Legal Name” and the library under “Organizational Unit.”
2 A museum with collections representing two or more disciplines (e.g., art and history)
3 A museum with collections limited to one narrowly defined discipline (e.g., textiles, stamps, maritime, ethnic group)
4 Verify that your organization has a D-U-N-S® Number or take steps to obtain one. Your organization can receive a D-U-N-S® Number at no cost by calling the dedicated toll-free D-U-N-S® Number request line at 1-866-705-5711 or by visiting www.dnb.com/us.
5 Congressional Districts can be found by inserting the zip code of the institution at the following site: http://www.house.gov/representatives/find.
6 For nonprofit tax filers Total Revenue can be found on line 12 of the IRS Form 990.
7 For nonprofit tax filers Total Expenses can be found on line 18 of the IRS Form 990.
8 For organizations applying in the Digital Library category, please address:
• services to your community including services to other organizations and services to end users;
• access to resources;
• sustainability and preservation plans for the digital library;
• accessibility to people with disabilities (e.g., compliance with the Americans with Disabilities Act).
9 Academic and research libraries may interpret “community” as your campus community and/or local community.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Mark Feitl |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |