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pdf2017 Nomination Form—Page One
National Medal for Museum and Library Service
(To be filled out by the nominated organization.)
A. Cover Sheet
1. Legal Name of Your Organization:1
Organizational Unit (if different from Legal Name):
2. Organization Address
Street1:
Street2:
City:
County:
State:
Zip+4/Postal Code:
3. Telephone Number:
4. Fax Number:
5. Web Address: http://
6. Name of Organization’s Director/CEO:
Title:
E-mail:
Telephone Number:
7. Your Name (the person completing this form):
Title:
E-mail:
8.
Telephone Number:
Type of Institution (check one):
Academic Library
Aquarium
Arboretum/Botanical garden
Art Museum
Children’s/Youth Museum
Digital Library
General Museum2
Historic House/Site
History Museum
Library Association
Library Consortium
Museum Library
Natural History /Anthropology Museum
Nature Center
Planetarium
Public Library
Research Library/Archives
School Library, or School District applying
on behalf of a School Library or Libraries
Science/Technology Museum
Special Library
Specialized Museum3
Zoo
Other, please specify:
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)
1
2017 Nomination Form—Page Two
National Medal for Museum and Library Service
(To be filled out by the nominated organization.)
A. Cover Sheet (continued)
9. Governing Control (check one):
State Government
County Government
City or Township Government
Special District Government
Regional Organization
U.S. Territory or Possession
Independent School District
Public/State-Controlled Institution of Higher
Education
Indian/Native American Tribal Government (Federally
Recognized)
Indian/Native American Tribal Government (Other
than Federally Recognized)
Public/Indian Housing Authority
Nonprofit with 501(c)3 IRS Status (Other than Institution
of Higher Education)
Nonprofit without 501(c)3 IRS Status (Other than
Institution of Higher Education)
Private Institution of Higher Education
Individual
For-Profit Organization (Other than Small Business)
Small Business
Hispanic-Serving Institution
Historically Black Colleges and Universities (HBCUs)
Tribally Controlled Colleges and Universities (TCCUs)
Alaska Native and Native Hawaiian Serving Institutions
Nondomestic (non-U.S.) Entity
Other, please specify:
10. Nominated Organization’s D-U-N-S® Number:4
11. Nominated Organization’s Employer/Taxpayer Number (EIN/TIN):
12. Congressional District of Nominated Organization5:
13. Organization’s Annual Operating Budget:
14.
A. Fiscal Year
B. List Total Revenue6/
Support Income
C. List Total Expenses/
Outlays7
Difference between
B. Total Revenue and
C. Total Expenses
15. 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.
16. Has your organization had an A-133 audit in the past three years? Yes No
17. If no, has your organization had a financial statement audit in the past three years? Yes No
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® Num
ber 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 entering the zip code of the institution at 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.
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2017 Nomination Form—Page Three
National Medal for Museum and Library Service
(To be filled out by the nominated organization.)
A. Cover Sheet (continued)
18. 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.)
19. If yes, please explain.
20. Number of full-time paid organization staff:
Number of part-time paid organization staff:
Number of full-time unpaid organization staff (including
Number of part-time unpaid organization staff (including
volunteers):
volunteers):
21. Total number of days the organization was open to the public for the past 12-month period prior to application:
22. Name of Nominating Individual:
Title:
Relationship to Organization:
E-mail:
Telephone Number:
2017 Nomination Form—Page Four
National Medal for Museum and Library Service
(To be filled out by the nominated organization.)
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 font)
y
y
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.
C. Narrative8 (not to exceed four single-spaced pages; no less than 12-point font)
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.
1. Describe the community9 and the particular community needs addressed.
y
y
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?
2. Describe the programming your organization has developed for these particular community needs. (see section C.1.)
y
y
y
y
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 develop
ment 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.
3. Describe what impact your organization’s programs and services have had on the identified community needs.
y
y
y
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?
4. Describe your organization’s financial situation.
y
y
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)
y
y
y
These letters should come from community members who have direct knowledge of your organization’s community ser
vice. 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.
For organizations applying in the Digital Library category, please address:
y services to your community including services to other organizations and services to end users;
y access to resources;
y sustainability and preservation plans for the digital library;
y accessibility for 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.
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2017 Nomination Form—Page Five
National Medal for Museum and Library Service
(To be filled out by the nominated organization.)
Website - https://www.imls.gov/node/7488/
Download FY 2017 Nomination Form (Fill-in PDF, 147KB)
Visit the National Medals page in our National Initiatives section to learn more about the annual celebration of the National Medal
recipients.
Deadline:
October 3, 2016
Program Contact for Museums:
Mark Feitl, Museum Program Specialist
202-653-4635
[email protected]
Program Contact for Libraries:
Katie Murray, Staff Assistant
202-653-4644
[email protected]
Program Overview:
The National Medal honors outstanding libraries and museums that have made significant and exceptional contributions in ser
vice 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:
y
y
y
y
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:
y
y
y
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 government or a private nonprofit organization that has tax-exempt status under the Internal
Revenue Code State or local government or a private nonprofit organization that has tax-exempt status under the Inter
nal 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:
y a museum that, using a professional staff, is organized on a permanent basis for essentially educational or aes
thetic 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.
2017 Nomination Form—Page Six
National Medal for Museum and Library Service
(To be filled out by the nominated organization.)
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?
y If an institution self-nominates, it simply needs to submit the nomination materials to IMLS by the deadline.
y 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
OMB Numbers 3137-0029, 3137-0071, Expiration Date: 7/31/2018
IMLS-CLR-F-0014
| File Type | application/pdf |
| File Title | 2017 NMMLS Nomination Form |
| Subject | national medal |
| File Modified | 2016-06-06 |
| File Created | 2016-05-27 |