Form National Medal Nom National Medal Nom National Medal Nomination Form

2022 Nomination Form

National Medal for Museum and Library Service

(To be completed by the nominated organization)

Section A

1. Nominated Organization

Legal Name of the Nominated Organization

If your organization is not eligible on its own, then enter the name and address of the eligible entity under “Legal Name.” For example, if your organization is a library that is part of a university, list the university under “Legal Name” and the library under “Organizational Unit.”

Organizational Unit (if different from Legal Name)

2. Nominated Organization Address

Street 1

Street 2

City

County

State/Territory

Postal Code

3. Nominated Organization Telephone Number

Telephone Number

4. Nominated Organization Web Address

Web Address

5. Nominated Organization’s Director/CEO

Name of Nominated Organization’s Director/CEO

4

Title

E-mail

Telephone Number

6. Person Completing This Form

Name of Person Completing This Form

Title

E-mail

Telephone Number

7. Type of Organization

Type of Organization (check one)

• Academic Library

• Aquarium

• Arboretum/Botanical Garden

• Art Museum

• Children’s/Youth Museum

• Digital Library

• General Museum - A museum with collections representing two or more disciplines (e.g., art and history)

• 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 Museum - A museum with collections limited to one narrowly defined discipline (e.g., textiles, stamps, maritime, ethnic group)

  

• Zoo

• Other, please specify

8. Governing Control

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

• Hispanic Serving Institution

• Historically Black Colleges and Universities (HBCUs)

• Tribally Controlled Colleges and Universities (TCCUs)

  

• Alaska Native and Native Hawaiian Serving Institutions

• Other, please specify

9. Nominated Organization’s D-U-N-S® Number

D-U-N-S® Number

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(link is external).

10. Nominated Organization’s Employer/Taxpayer Number (EIN/TIN)

Employer/Taxpayer Number (EIN/TIN)

11. Congressional District of Nominated Organization

Congressional District of Nominated Organization

Congressional Districts can be found by entering the ZIP Code of the organization at http://www.house.gov/representatives/find (link is external).

12. Nominated Organization’s Annual Operating Budget

Annual Operating Budget

13. Nominated Organization’s Financial Information

Most recently completed fiscal year (FY)

A. Most recently completed FY (insert year)

B. List Total Revenue/ Support Income

For nonprofit tax filers Total Revenue can be found on line 12 of the IRS Form 990.

C. List Total Expense/ Outlays

For nonprofit tax filers Total Expenses can be found on line 18 of the IRS Form 990.

Difference between B. Total Revenue and C. Total Expenses

Second most recently completed fiscal year (FY)

A. Second most recently completed FY (insert year)

B. List Total Revenue/ Support Income

For nonprofit tax filers Total Revenue can be found on line 12 of the IRS Form 990.

C. List Total Expense/ Outlays

For nonprofit tax filers Total Expenses can be found on line 18 of the IRS Form 990.

Difference between B. Total Revenue and C. Total Expenses

If the nominated organization had a deficit greater than 10% of its operating budget for either of the fiscal years listed above, please explain the circumstances of this deficit.

14. Audits and Material Weaknesses

Has the nominated organization had an A-133 audit in the past three years?

• Yes

• No

If no, has the nominated organization had a financial statement audit in the past three years?

• Yes

• No

Were there any material weaknesses identified in the nominated organization’s prior year’s audit report?

(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.)

• Yes

• No

• N/A

If yes, please explain.

15. Staff

Number of full-time paid organization staff

Number of full-time unpaid organization staff (including volunteers)

Number of part-time paid organization staff

Number of part-time unpaid organization staff (including volunteers)

16. Total Number of Days Open

Total number of days the nominated organization was open to the public for the past 12-month period prior to application

17. Nominator

Name of Nominator

Title

E-mail

Relationship to Organization

Telephone Number

Section B. Overview and Narrative

The National Medals program recognizes outstanding libraries and museums of all types and sizes that deeply impact their communities by, for example:

• fostering a lifelong passion for learning for all people, nourishing curiosity and imagination from early childhood through adulthood, for people of all abilities and needs;

• providing access to information through advancing digital capacity, focusing on digital inclusion and access to digital and informational resources, including e-books and materials to help address workforce development and public health;

• transforming the lives of community members by being trusted community spaces for convening, connection, and conversation; enlightenment and shared thoughts and opinions; and preserving natural and cultural heritage and community memory;

• continuing to engage their communities during the ongoing coronavirus pandemic, and planning for the institution’s future, with enhanced focus on diversity, equity, and inclusion, through providing information, programming, and services virtually, or taking innovative and imaginative steps toward continuing services and reopening their physical spaces.

Referencing what is important, unique, and distinctive about your institution, please respond to the following prompts from the point of view of the nominated organization in no more than five pages (3,000 words):

Overview (no more than one page)

• Summarize the nominated organization’s mission or statement of purpose.

• Provide a brief history of the nominated organization.

• Explain why you believe the nominated organization deserves to win the National Medal for Museum and Library Service.

Narrative (no more than four pages)

1. Community and Community Needs

• Describe your community, including its demographics.

• Describe the community’s major needs and how you identified them.

• In what ways does your staff work with the community?

Note: Academic and research libraries may interpret “community” as your campus community and/or local community.

2. Programs and Services

• Referring to the community and its major needs you identified in Section C.1, describe the specific programs and services that have been developed to address one or more of those needs.

• Provide a brief description of your full portfolio of programs and services as context for those described above.

• How have you constructed community partnerships to increase your ability to connect with targeted population groups within your community?

• Describe how you serve community members of all abilities.

Note: Organizations identified as Digital Libraries should address:

• services to your community including services to other organizations and services to end users;

• how an understanding of audiences, either current or potential, has driven the approach to providing access to your organization's programs and resources;

• sustainability and preservation plans for the digital library; and

• accessibility for people with disabilities, including persons with print disabilities.

3. Impact

• Describe the impact of your organization’s programs and services on the identified community needs. Be specific, using qualitative, quantitative, or both types of descriptors as appropriate.

• How does your organization track the cumulative impact of its programs and services through time?

• How has your organization used these data to inform continuing and/or new programs and services?

4. Financial Sustainability

• List your organization’s three primary sources of revenue.

• Describe how your organization financially supports the programs and services discussed above. Does your organization have a sustainable funding model that will continue to enable these programs and services?

• Identify any private or non-profit groups that support your organization’s mission and activities and describe the extent of their support.

Overview and Narrative

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Section C. Letters of Support

• Letters should come from community members who have direct knowledge of the nominated organization’s community service and the particular programs identified in the nomination. We recommend that the letters come from different segments of the broader community served by the organizations and from individuals who have either witnessed or experienced first-hand a particular program or service.

• Upload community letters of support with this nomination form or email them to [email protected].

• In addition to the three community letters of support, letters from members of Congress are welcome. They must be emailed to [email protected].

• Address all letters to the Director of the Institute of Museum and Library Services.

Letter #1

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Letter #2

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Letter #3

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