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Lead-Safe Indiana Awards 2004

Application Form

 

A single person or organization can be the catalyst for change. We have seen it in communities across Indiana. One legislator, one neighborhood leader, one hospital, one concerned parent, one mayor, one health department employee can bring about tremendous change — change that helps children today and well into the future.

The Lead-Safe Indiana Task Force recognizes and cultivates local leadership. At the 2004 Indiana Lead-Safe and Healthy Homes Conference on November 10, the Task Force will give awards to those leaders who have made a difference. The purpose of these awards is not only to acknowledge leadership but to inspire others.

Please look around your community – at yourself – and make a nomination.  Award guidelines and forms are available at www.ikecoalition.org or from Dave McCormick at 317-221-2171 or dmccormi@hhcorp.org.  Don’t be shy! 

Nominee Information:

Name of Nominee: _____________________________ If an organization, number of employees:  ____________

Organization Type: (circle one)

  • Government  
  • Nonprofit Organization
  • Hospital
  • Business
  • Individual

Name of Contact Person: ________________________ Address: ____________________________________

City: ___________________ State: __________ ZIP Code: ___________ County:  ____________________

Daytime Phone Number: _______________ Fax Number: ______________ E-mail Address: _________________

Person Submitting Nomination (if different from above):

Name of Nominee: _____________________________ If an organization, number of employees: _____________

Organization Type: (circle one)

  • Government
  • Nonprofit Organization
  • Hospital
  • Business
  • Individual

Name of Contact Person: ________________________ Address:_____________________________________

City: ___________________ State: __________ ZIP Code: ___________ County: _____________________

Daytime Phone Number: _______________ Fax Number: ______________ E-mail Address: _________________

Is the person/organization being nominated aware of the nomination?    Yes   No

Provide a brief summary of the project for data entry purposes only. The review committee will judge your project based on your complete answers to the questions on of the awards informational brochure.

 

 

 

 

In an attachment, answer the following questions. Please keep it to less than four pages.

  1. Describe leadership effort by individual or organization.
    • Who or what area benefited by the effort?
    • What is the background of the individual or organization?
    • What was done?

     

  2. Explain why the effort demonstrates leadership.
    • Is it innovative?
    • Is it comprehensive?

     

  3. Provide a description of the results of the effort.
    • Are there any measurable results?
    • How did the effort make a difference?

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