Samuel L. Katz, M.D. Excellence in Immunization Award
Samuel L. Katz, M.D. Excellence in Immunization Award
Samuel L. Katz, M.D. Excellence in Immunization Award
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<strong>Samuel</strong> L. <strong>Katz</strong>, M.D.<strong>Excellence</strong> <strong>in</strong> <strong>Immunization</strong><strong>Award</strong>Complete and submit the nom<strong>in</strong>ation package describ<strong>in</strong>g the outstand<strong>in</strong>g contributionsof the organization, project or person be<strong>in</strong>g nom<strong>in</strong>ated.Name of Organization, Project or Person:______________________________________Agency Contact:__________________________________________________________Address: _______________________________________________________________Phone: _______________ Fax: ________________ Email:______________________Name of Program/Activity/Policy: ____________________________________________Date of Program Inception (If applicable): ____________________________________Nom<strong>in</strong>ated By: _____ Agency Contact _____ Other (complete <strong>in</strong>formation below)Name/Title: _____________________________________________________________Organization: ____________________________________________________________Address: _______________________________________________________________Phone: _____________ Fax: __________________ Email:______________________Deadl<strong>in</strong>e for submission: June 20, 2011Submit nom<strong>in</strong>ation package to:Andrea HeldNC <strong>Immunization</strong> Branch1917 Mail Service CenterRaleigh, NC 27699-1917Fax: (919) 870-4825Email: andrea.held@dhhs.nc.govQuestions, please contact Andrea Held with the N.C. <strong>Immunization</strong> Branch at(919) 707-5564 or andrea.held@dhhs.nc.gov
<strong>Samuel</strong> L. <strong>Katz</strong>, M.D. <strong>Excellence</strong> <strong>in</strong> <strong>Immunization</strong> <strong>Award</strong> Nom<strong>in</strong>ationNarrativeAnswer the follow<strong>in</strong>g questions on a separate sheet of paper Nom<strong>in</strong>ations willbe reviewed on a 100 - po<strong>in</strong>t scale with the follow<strong>in</strong>g maximum po<strong>in</strong>ts for eachcategory:1. Mission: What is the mission of the organization and the purpose of theprogram/project? (10 po<strong>in</strong>ts)2. Collaboration/Partnerships: What community and organizationalpartnerships were formed to support the program/project? What are the roles,responsibilities and contributions of each partner? (20 po<strong>in</strong>ts)3. Community Responsiveness: Who is the program designed to serve? Howhas the community been <strong>in</strong>volved <strong>in</strong> the design, implementation and evaluationof the program? How is the program responsive to unique community needs?(15 po<strong>in</strong>ts)4. Innovation: What creative features of the program make it unique, excit<strong>in</strong>gand/or newsworthy for the community served? (20 po<strong>in</strong>ts)5. Outcomes and Evaluation: What are the outcomes of the program/projectand how was it evaluated? Outcome measures could <strong>in</strong>clude changes ofimmunization rates, number of participat<strong>in</strong>g organizations, etc. (15 po<strong>in</strong>ts)6. Replication: What is the potential for replicat<strong>in</strong>g this project/program <strong>in</strong> othercommunities? (15 po<strong>in</strong>ts)7. Sample Materials: Submission of program materials is encouraged. Samplematerials <strong>in</strong>clude brochures, posters, videos, campaign materials, news articles,etc. Sample materials will not be returned. (5 po<strong>in</strong>ts) Please mail materials, byJune 20, 2011 to:Andrea HeldNC <strong>Immunization</strong> Branch1917 Mail Service CenterRaleigh, NC 27699-1917
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