Nominator's Template

Young Leader Awards: Recognizing Leadership for a Healthier America

The Robert Wood Johnson Foundation (RWJF) will honor up to 10 leaders age 40 and under who offer great promise for leading the way to improved health and health care for all Americans. The Young Leader Awards will be given to individuals who have demonstrated innovative leadership in health and health care. Nominations should come only from people who know their candidate well, who are personally inspired by them and who are personally completing the nomination forms. A candidate may not nominate him or herself, or be a member of the family (e.g., spouse, sibling, child, or parent) of the nominator.

To view the Call for Nominations and complete information about selection criteria and nomination requirements, visit RWJFyoungleaderawards.org.

Nominations will be accepted beginning May 31, 2012. Nominators must complete and submit this template and a five-page statement (see below) to the Institute for Alternative Futures via email to no later than July 16, 2012, 11:59 pm Eastern Time. The separate Nominee Template must also be completed by the nominee and sent to IAF at the above email address by the same deadline.

Date:
NOMINEE
Name:
Date of Birth:
Title:
Employer:
Email Address :
Telephone Number:
NOMINATOR
Name:
Title:
Employer:
Email Address :
Telephone Number:

A.  In the list below, please mark with an “X" the young leader characteristics sought, as stated in the Call for Nominations, to which you will speak in this nomination.

__ Meeting an Important Need through Innovation

__ Accomplishments that Represent Collective Efforts

__ Demonstrated Empathy, Care and Commitment

__ Transdisciplinary Understanding

__ Curiosity

__ Combined Thinking and Action

__ Sustainable Impact

B.  Separately from your response to Part C, please briefly explain your relationship to the nominee.
C.  In no more than five pages, using 12-pt Times New Roman with 1” margins:
§  Address as many of the young leader characteristics sought as possible.
§  Provide concrete examples showing how the nominee has demonstrated the characteristics sought for future leaders. Highlight at least two examples of the candidate’s abilities to lead and innovate, including descriptions of relevant work.

D.  Nominator Certification

I, the nominator, hereby certify that:

·  All the statements I have provided are true and correct.

·  I am not staff or family of staff of the Robert Wood Johnson Foundation, the Institute for Alternative Futures, or the Awards Panel.

·  I am not a Trustee of the Robert Wood Johnson Foundation or related by blood or marriage to any Officer* or Trustee of the Robert Wood Johnson Foundation, or a descendant of the Foundation’s founder, Robert Wood Johnson.

* The Officers are the Chairman of the Board of Trustees, President and CEO, Chief of Staff, General Counsel & Secretary, and Treasurer of the Foundation.

·  I am not a member of the family (e.g., spouse, sibling, child, or parent) of the nominee.

·  I have permission from the nominee to nominate them.

To certify these statements, please type or print your name and date: