A complete nomination includes one (1) copy of each of the
following:
- Completed application cover page.
- Executive summary of the program (one
single-sided page maximum)
- Brief overview of the program's sponsoring
organization (the structure, facilities, and services of
the hospital or healthcare organization) and a description of the
community served by the organization (population size, general
demographics, major employers, primary social and healthcare
factors). (1 single-sided page maximum)
- The program "story" - please include the
following: (3 single-sided pages maximum):
- an overview of when, how, and why the program
was conceived and developed, how it is structured, what its
operating costs and funding sources are, and how it meets the
unique needs of the community - a YouTube url of
your supporting video (not
required) (5 minute maximum). See FAQ. Supporting
photographs are acceptable;
- a partnership statement outlining the types of
partnerships and alliances needed for and created as a result of
the program, such as with physicians, other healthcare
organizations, businesses, and government agencies;
- an impact statement, including statistics on the number of
people served, quantifiable improvements in health status/access,
the response from the community, etc;
- We strongly encourage you to focus on the outcomes your program
has acheived, rather than the activities in which it engages;
- We encourage you to share your program's impact through
individual beneficiary's eyes, in addition to the program's overall
impact;
- a sustainability statement, including
information about ongoing costs and funding sources;
- lessons learned from the development,
implementation, and results of the program;
- future goals for the program such as
maintaining or expanding the program, and;
- a replication statement regarding if and how
this program or a similar program could be replicated in other
communities.
- The most recent annual report for the program
if available.
Download the application form by clicking here: Nomination Form