Questionnaire for Nominated Program or Organization

The organization should save this form to a computer as “Nominator Questionnaire Template.” The nominated organization/program representative will complete one and save it as “Organization Nominator.”Send the Questionnairetemplate to the three non-staff nominators. Each completes a separatequestionnaire, saves it, and sends it to the organization electronically. The organization saves each document individually as Nominator #1, or Nominator #2, or Nominator #3. The four documents will be uploaded as four attachments.

Nominator # __: To be completed by someone who knows the organization being nominated.

Name of Nominated Organization
Name of Nominated Program (if applicable)
Your Name (Nominator)
Your Business or Organization (if applicable)
Title (if applicable)

Address

Office Phone Number

Email

Please indicate your role and the years you have been involved with the organization and program.
____ Board Member / Years Involved:
____ Advisory Board Member / Years Involved:
____ Volunteer / Years Involved:
____ Consumer, patient, client / Years Involved:
____ Funder / Years Involved:
____ Partnering Organization / Years Involved:
____ Other (please indicate role and years involved)
How did you learn about The Blue Foundation for a Healthy Florida Sapphire Award?
______I formally affirm that I have personally written this nomination in my words. I understand that nomination comments may be used for promotional purposes. [Nominator inserts initials to affirm.]
Date

Information Requested

We recognize that each nominator will have a different perspective in these eight areas. Please tell as much as you can in your own words by using your knowledge, your experiences and your story of how the nominated organization or nominated program demonstrates excellence in community health programming.

1. Demonstrated Success. State as factually as you can exactly how the nominated organization or the nominated programhas significantly improved access to health care and improved the health-related outcomes of the uninsured and/or underserved. Noting clear, demonstrated evidence of success is critical for reviewers to understand the validity of claims about impact. (750 words or less)

Examples might include, but are not limited to:

  • Specific information about client goals, tracking and data collection to demonstrate success.
  • Specific data such as annual increases in youth immunization rates, control of hypertension by reductions in adult blood pressure at check up intervals, reduction in obesity and diabetes risk by weight and blood sugar control (HA1c testing), control of asthma as noted by reduction in annual emergency room visits and sick days, indicators of compliance in taking medications or maintaining sobriety, etc.
  • Success in helping change or refine health-related public policies or established standards of practice.
  • Non-health-based strategies used to ensure that health and broader outcomes are achieved, such as approaches to improve affordable housing, childcare availability, legal services and other elements that may be part of strategies for success.
  • Substantially increasing general or expert volunteerism; improving access to transportation, which results in better patient compliance to make medical appointments; linkages to job training for adults or structured out-of-school activities for youth; obtaining free or reduced cost pharmaceuticals or medical procedures; setting a precedent for focusing on a type of needed community service.
  • Verbatim testimonials from clients.

INSERT your response here.

2. Leadership. Describe the ways in which the nominee’s leaders mobilize the nominated organization or program, engage the community, leverage resources and earn trust. Describe how the nominee’s leaders have innovated and overcome obstacles to improve access to quality care. (500 words or less)

Insert your response here.

3. Sustainability.Explain how the nominee builds on existing community assets and resources, fosters systemic change, and/or develops lasting policy changes that can sustain the nominated organization or nominated program and improve health for the uninsured and underserved. (500 words or less)

Insert your response here. Take note of page limits.

4. Community Outreach. Explain how the nominee employs proven strategies to ensure awareness and availability of organizational/programmatic resources, and how the uninsured/underserved can access such resources. (500 words or less)

Insert your response here. Take note of page limits.

5. Strengthening Standards. Explain how the nomineeengages in activities that are professionally recognized and uphold established professional standards for excellence. This may also include the ways in which program activities and organizational practices are research-based, serve as a model for others and are replicated by others. (Maximum 500 words or less)

Insert your response here. Take note of page limits.

6. Program Evaluation. Demonstrate how the nominee engages in the systematic and continuous examination of organizational activities and goals and client outcomes. Describe the specific measures and methods that the nominee employs to track, analyze and use data to improve the organization and its outcomes. (500 words or less)

Insert your response here. Take note of page limits.

7. Culturally Competent. Describe the extent to which nominee embraces and respects the unique strengths and needs of diverse populations. (e.g., organizational programs and policies are affordable, provide spoken and written language assistance, involve client participation in program development and implementation, etc.). (500 words or less)

Insert your response here. Take note of page limits.

8. Accountability. Provide documentation that the nominee’sfinancial and administrative practices meet professional and ethical standards. Provide independent audits that reveal thorough, accurate and honest financial and administrative practices. (500 words or less)

Insert your response here. Take note of page limits.

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