(page 1 of 13) GSK IMPACT Awards Application 2018 Registration Deadline: Friday, March 30, 2018 Application Deadline: Friday, May 4, 2018
(page 2 of 13) Before completing this form, please review the GSK IMPACT Award 2018 Registration and Application Instructions document in full to ensure that your organization is eligible and competitive for a GSK IMPACT Award. To complete the application, download a copy of this form to your own computer, and click in the gray box to begin typing boxes will expand automatically. The application has five sections 1) Organizational Information, 2) Financial Information, 3) Client Information, 4) Application Questions, and 5) Detail on Program(s). All sections of the application must be completed. The application must be signed and dated (final page) prior to submission unsigned applications will not be accepted. PART 1: Organizational Information Organization Name (Legal IRS Name) Organization AKA Name (if applicable) Is organization a 501(c)(3)? YES NO (If no, then not eligible) Year organization received 501(c)(3) status: (Ruling date): EIN#: State: (Must be a 501(c)3 nonprofit organization) Organization Overview/Mission Brief overview of organization (no more than three sentences) Which GSK IMPACT Awards Program are you applying to? Greater Philadelphia Region Triangle Region: ORGANIZATION CATEGORY Please check the category(ies) for your organization (as many as apply) Nutrition & Physical Activity Education Housing & Built Environment Employment & Income Community Safety Family & Social Support Programs that support: Healthy eating, exercise, sports, outdoor activity, etc. to help members of the community achieve or maintain a healthy weight. Programs that support: Literacy, life skills, early learning and learning engagement, teacher support/development, curriculum quality improvement, coaching/mentorship etc. to help members of the community graduate high-school or go onto post-secondary education. Programs that support: Shelter, safe housing conditions, home assistance, home ownership, transit systems, parks and green spaces, etc. that help to build healthy, connected neighborhoods. Programs that support: Job skills, professional training, resume assistance, career counseling, interviewing skills, etc. that help to reduce unemployment. Programs that support: Healthy neighborhoods, safe streets, crime reduction, civil rights advocacy, community centers, etc. that help to build safe neighborhoods that are free from violence. Programs that support: After-school support, life coaching/mentorship, elderly care and engagement, child care assistance, parenting support, counseling, etc. that help to reduce isolation and increase community engagement and support. Street address (street, city, state, zip) County(ies) served (Must include at least one of the following counties to be eligible: In Greater Philadelphia Bucks, Chester, Delaware, Montgomery, and/or Philadelphia Counties in PA; in the Triangle Region Chatham, Durham, Orange and/or Wake Counties in NC) Executive Director (Name, title, office/cell phone, and email) Additional contact (Name, title, office/cell phone, and email) Organization Phone Organization Website Organization Social Media (List account handles or URL for all that are applicable) Twitter: Facebook: Instagram: LinkedIn: Other: Staff size Full-time: Part-time: Volunteer:
(page 3 of 13) ORGANIZATION CATEGORY (continued) BOARD OF DIRECTORS Please note the number where applicable Total Number of Directors on Board: Women: Immigrants: Differently Abled: Caucasian: Black/African American: Latino or Hispanic: Native American: Asian/Asian American: Native Hawaiian/Other Pacific Isl: LGBTQ+: Other: Does 100% of your board of directors contribute financially to the organization? YES NO; If no, then please explain: SENIOR MANAGEMENT Please note the number where applicable Total Number of Senior Management: Women: Immigrants: Differently Abled: Caucasian: Black/African American: Latino or Hispanic: Native American: Asian/Asian American: Native Hawaiian/Other Pacific Isl: LGBTQ+: Other: Please describe how your staff represents the demographics that you serve: Does your organization, as suggested by the IRS in Part VI, Section B of the Form 990, have: 1) conflict of interest policies; 2) whistleblower policy; 3) independent process with comparability data for determining compensation; and does your organization 4) provide a copy of the 990 to board members prior to filing? YES NO; If no, then please explain: Is organization a past GSK IMPACT Award Winner? YES NO If yes, then list year (If 2016 or 2017 Winner, then not eligible): Is organization a current GSK grantee? YES NO (If 2018 calendar year GSK charitable grantee, then not eligible) PART 2: Financial Information Organizational total revenue Current fiscal year: $ Previous fiscal year: $ Notes: Does not include in-kind donations Current year figures are based on board-approved budget forecasts; previous year figures are based on the organization s audited statement of activities or completed 990. If total revenue in current or previous fiscal year is less than $160,000 or more than $5 million, then not eligible Last Fiscal Year Support: (actual or estimated) Amount % of Budget Government $ % Fees/earned income $ % Individual donors $ % Foundations & Corporations $ % Other (specify) $ % Totals $ 100% List of top funders:
(page 4 of 13) PART 2: Financial Information (continued) Complete the following chart with the financial information for the organization covering the current and previous three years. Current year figures should be based on board-approved budget forecasts; three previous years should be based on the audited statement of activities or completed 990. Most competitive applications will demonstrate evidence of sound financial condition for three years or more. Operating Budget /Results Revenue Expense Surplus/(Deficit) Current Year (Budget) FY end date: (ex: June 30, 2017) Previous Year (Actual) FY end date: 2 Years Prior (Actual) FY end date: 3 Years Prior (Actual) FY end date: Unrestricted Liquid Net Assets Did the organization have any surpluses or deficits that exceeded 10% of its annual operating budget? YES NO If yes, then please explain: PART 3: Client Information Number served annually (Total population served) Client location(s) (county, city, neighborhood, etc.) Gender of those served: % female % male % non-binary Age: % pre-kindergarten % elementary age % middle school age % high school age % adults % seniors/elders Ethnicity: % Caucasian % Black or % Latino or Hispanic African American % Asian or % Native American % Native Hawaiian/ Asian American Other Pacific Islander % Other Other: % Percentage of population served that is below federal poverty guidelines % Veteran % Physically % Mentally Challenged Challenged % Immigrants % Incarcerated % Substance Abuse % Orphaned Children % History of % Other; (have lost one or Domestic Violence please specify: more parents)
(page 5 of 13) PART 4: Application Questions Summarize what your organization does and why it should be considered for a GSK IMPACT Award: (250 words) What is the community need(s) that your organization addresses and how does it affect health outcomes? (150 words) The GSK IMPACT Awards recognize local non-profit organizations that are making communities healthier places to live, learn, work and play, based on a model of population health called the County Health Rankings & Roadmap. While many of these factors (1- Nutrition and Physical Activity, 2- Education, 3- Housing & Built Environment, 4- Employment and Income, 5- Community Safety or 6- Family & Social Support) are not traditionally thought of as health factors, competitive applications will clearly articulate the connection between the community need(s) that your organization addresses and health outcomes. How does your organization address these community needs and why have you selected that approach? (150 words)
(page 6 of 13) PART 4: Application Questions (continued) How do you include, respond, and adapt to the community that your organization works with? (150 words) Please describe how your organization uses quantitative and qualitative data to inform the design, implementation, evaluation, and continuous improvement of your program(s): (150 words) Please list up to five organizations that you partner with and describe how these meaningful partnerships have contributed to better outcomes than if your organization were working alone. Please also include the partner organization s website: (This question is intended to identify partners who have an active role in service provision, program implementation, or broader community change. Please do not list funders unless they partner with your organization beyond funding. You may list less than five.) 1. 2. 3. 4. 5. Please describe how your organization demonstrates operational excellence: (150 words) (e.g. employee and Board development; sound governance; strategic planning; financial stability; volunteer support; diverse and effective leadership; etc.)
(page 7 of 13) PART 4: Application Questions (continued) Please describe how your organization s work is part of a larger movement to improve the health of the community this could include influencing systemic reform, engaging with regional or local planning efforts, and/or your programs being replicated in other communities or scaled in your community: (150 words) Please share a success story that demonstrates how your work improves health outcomes for an individual or individuals in the community: (250 words) Please share a lesson you have learned that you are using to improve the effectiveness of your organization: (150 words)
(page 8 of 13) PART 5: Detail on Program(s) Please list and describe up to three programs that your organization administers that you would like considered in your application for a GSK IMPACT Award. List the programs in order of priority. In this section, please describe the social impact your programs have had on the community with a particular focus on improving health outcomes. We are not only interested in understanding the numbers of individuals reached or programming delivered, but also what impact you know (or believe) these interventions are having in the lives of individual clients and/or the community at large. For each measure, we will ask you to describe how you are capturing this data this includes tracking (e.g. surveys or other measurement tools), estimation (e.g. informed guesses by staff or inferred measures from other reports or studies), or speculation (e.g. anecdotal evidence). Notes: Please describe up to three relevant programs in the application we expect the program descriptions to represent a majority (or close to a majority) of the organization s overall budget. For example, if you list only one program and it represents just 10% of the overall budget, your application may not be competitive. If your organization runs only one program, then simply list the name of the organization as Program #1. You do not need to complete Program #2 and #3. This section should describe current or past programs, not those that you plan to implement in the future. Program #1 Title: Addresses the following Health Category: Percent of overall organization budget: % Program description: (Suggested format We help [who] achieve [what successful outcome] through [summary of your services]. ) Describe intervention(s): (In a single sentence per entry (up to four); identify each of the core services or activities your program uses to achieve its goal.) Note: This should be a high-level summary of your program s intervention, not a detailed itemization of implementation tasks. 1. 2. 3. 4. Describe program reach and social impact: (Please respond to questions 1 4 below) 1. How many people are served by this program? (This response should be a number) 2. How are you measuring the number of people served by this program? (This response should describe your means of measurement examples include attendance logs, surveys, public data, etc.)
(page 9 of 13) PART 5: Detail on Program(s) (continued) 3. Describe the social impact you aim to achieve in relation to this program what is the state of improved well-being that the people you work with achieve? (Examples include: number of people who are no longer overweight, reduced rates of violence, improved safety or injury rates, increased social networks and supports, number of people housed, improved commute times, etc.) 4. How many people are achieving the social impact described above? In other words, how do know that your interventions are having the desired effect? (This response should include both a number and a description of your means of measurement examples include surveys, pre- and post-tests, focus groups, public data, etc. as well as the rationale for why this measurement points to your intended social impact.) Program #2 Title: Addresses the following Health Category: Percent of overall organization budget: % Program description: (Suggested format We help [who] achieve [what successful outcome] through [summary of your services]. ) Describe intervention(s): (In a single sentence per entry (up to four); identify each of the core services or activities your program uses to achieve its goal.) Note: This should be a high-level summary of your program s intervention, not a detailed itemization of implementation tasks. 1. 2. 3. 4.
(page 10 of 13) PART 5: Detail on Program(s) (continued) Describe program reach and social impact: (Please respond to questions 1 4 below) 1. How many people are served by this program? (This response should be a number) 2. How are you measuring the number of people served by this program? (This response should describe your means of measurement examples include attendance logs, surveys, public data, etc.) 3. Describe the social impact you aim to achieve in relation to this program what is the state of improved well-being that the people you work with achieve? (Examples include: number of people who are no longer overweight, reduced rates of violence, improved safety or injury rates, increased social networks and supports, number of people housed, improved commute times, etc.) 4. How many people are achieving the social impact described above? In other words, how do know that your interventions are having the desired effect? (This response should include both a number and a description of your means of measurement examples include surveys, pre- and post-tests, focus groups, public data, etc. as well as the rationale for why this measurement points to your intended social impact.)
(page 11 of 13) PART 5: Detail on Program(s) (continued) Program #3 Title: Addresses the following Health Category: Percent of overall organization budget: % Program description: (Suggested format We help [who] achieve [what successful outcome] through [summary of your services]. ) Describe intervention(s): (In a single sentence per entry (up to four); identify each of the core services or activities your program uses to achieve its goal.) Note: This should be a high-level summary of your program s intervention, not a detailed itemization of implementation tasks. 1. 2. 3. 4. Describe program reach and social impact: (Please respond to questions 1 4 below) 1. How many people are served by this program? (This response should be a number) 2. How are you measuring the number of people served by this program? (This response should describe your means of measurement examples include attendance logs, surveys, public data, etc.) 3. Describe the social impact you aim to achieve in relation to this program what is the state of improved well-being that the people you work with achieve? (Examples include: number of people who are no longer overweight, reduced rates of violence, improved safety or injury rates, increased social networks and supports, number of people housed, improved commute times, etc.)
(page 12 of 13) PART 5: Detail on Program(s) (continued) 4. How many people are achieving the social impact described above? In other words, how do know that your interventions are having the desired effect? (This response should include both a number and a description of your means of measurement examples include surveys, pre- and post-tests, focus groups, public data, etc. as well as the rationale for why this measurement points to your intended social impact.) For Past GSK IMPACT Award Winners Only In order for a past GSK IMPACT Award winner to be considered again, organizations must demonstrate substantial, positive change and/ or significant development that has occurred in the program(s) since you received your GSK IMPACT Award. Please describe these changes or developments: (150 words) RULES FOR GSK IMPACT AWARDS 1. No applications will be accepted after the closing date, which is Friday, May 4, 2018. 2. Eligibility and awards are determined at the sole discretion of GSK. All decisions are final. Results of the judging will be conveyed in writing to the organizations. 3. By submitting an application, your organization consents to the use of any information (including the right to use your organization s name, logo, or associated trademarks) provided in your application for publicity purposes connected with the GSK IMPACT Awards. Applications submitted become the property of GSK and will not be returned. 4. As a condition of receiving the award, your organization may be asked to agree to further terms and conditions after the winners are selected. 5. GSK will produce high quality communication assets featuring the work of the winning organizations. For this purpose, a photographer will visit the winning organizations to obtain photographs. In the event your organization is selected as a winner, you hereby agree to execute a photographic release form provided by GSK. 6. Award winners must provide a brief report to GSK on how they have benefited from the award and how it was used. GSK may disseminate this information as a contribution to best practice. 7. GSK may use and publish the submissions referenced in item #6 above in connection with publicity of the awards. GSK also may edit these submissions for editorial purposes (e.g. to conform to space requirements in distribution platforms). 8. GSK will list our US Community Partnerships charitable contributions on our website. To that end, US Community Partnerships charitable contributions will be given under the condition that the recipient organization consents to public disclosure. Details disclosed may include but are not limited to the recipient organization s name, the award purpose, and the amount of the award. 9. U.S. Community Partnerships charitable awards are not made and cannot be used to influence or promote the use of GSK products.
(page 13 of 13) I certify I am the duly authorized officer or representative of the requesting organization and to the best of my knowledge, the information provided in this application is accurate. I understand and agree to provide additional documentation in support of the information provided if requested by GSK. (Representative must check box or application will not be valid) Additionally, if given a GSK IMPACT Award, the requesting 501(c)(3) organization must be willing to read GSK s Prevention of Corruption Third Party Guidelines (at https://www.gsk.com/media/3916/abac-third-party-guidelines.pdf) and agree to perform its obligations under the Agreement in accordance with the principles set out therein. By signing and submitting this Application Form, I confirm my organization s understanding and acceptance of the rules and conditions for application. The information in this Application Form is true to the best of my knowledge. Signature of CEO / Executive Director or Chief Financial Officer Date Title