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GSK IMPACT Awards for the Greater Philadelphia RegionApplication

Registration Deadline: Friday, May 1, 2015

Application Deadline: Friday, May 22, 2015

Table of contents

Application Form 2Rules for GSK IMPACT Awards 11Signature page 13Appendix 14

GSK IMPACT Awards for the Greater Philadelphia RegionApplication 2015

Application Form

Before completing this form, please review the GSK IMPACT Award 2015 Registration and Application Instructions (Greater Philadelphia) document in full to ensure that your organization is eligible and competitive for a GSK IMPACT Award.

Please download (“copy” or “save as”) this form as a Word document to your own computer. We ask that you name your completed form as GSK IMPACT Award Application Form (Greater Philadelphia) – Organization Name prior to uploading as part of the application process.

After you download a copy to your own computer, click in the gray box to begin typing – boxes should expand automatically.

Part I: Executive SummaryOrganization Name: (Legal IRS Name)

Organization AKA Name:(if applicable)

Organization Mission: (Short version; no more than three sentences)

Organization Overview: (Brief overview of organization’s history, programs and activities)

Organization Category: Primary Category Secondary Categories (if relevant)

(Enter the appropriate category for your organization – you may list one primary and up to two secondary categories: 1- Diet & Exercise, 2- Education, 3- the Built Environment, 4- Employment, or 5- Family & Social Support

Making the CaseIn no more than 500 words, summarize why your organization and programs are worthy of a GSK IMPACT Award. Please describe context about the nature and scope of the challenge that your organization seeks to address, the conditions and opportunities within the community; your organization’s response; what was achieved (include quantitative and qualitative data for the outcomes), with whom, how, and why it mattered; and what lessons were learned that are informing your current programming. If your organization is selected for a GSK IMPACT Award, this case study will be shared publicly so other organizations can learn from your success and possibly replicate your work.

Three Key Points: Throughout this case study, please make clear three things: 1) how the work targets and serves a disadvantaged population; 2) which category (factor that affects health) your program(s) addresses: Diet & Exercise, Education, the Built Environment, Employment, and/or Family & Social Support; and 3) how the organization and programs demonstrate IMPACT: Innovative, Measured, Partnered, Accountable, Community-centered and Transformative.

GSK IMPACT Awards for the Greater Philadelphia RegionApplication 2015 2

http://www.countyhealthrankings.org/health-factors/family-and-social-support


http://www.countyhealthrankings.org/health-factors/employment

http://www.countyhealthrankings.org/our-approach/health-factors/housing-transit

http://www.countyhealthrankings.org/health-factors/education

http://www.countyhealthrankings.org/health-factors/diet-and-exercise




http://www.countyhealthrankings.org/our-approach/health-factors/housing-transit



http://us.gsk.com/media/450846/gsk-impact-award-2015-registration-and-application-instructions-greater-philadelphia.pdf

http://us.gsk.com/media/450846/gsk-impact-award-2015-registration-and-application-instructions-greater-philadelphia.pdf


Part II: Detailed Information on OrganizationOrganization annual operating budget for current fiscal year

(Does not include in-kind donations)

Physical address (street, city, state, zip)

County location (Must be Bucks, Chester, Delaware, Montgomery, or Philadelphia County in PA to be eligible)

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)Is organization a customer or affiliate of a customer? YES NO

(If organization is a customer or affiliate of a customer as outlined in the eligibility section of the Instructions and Rules and Conditions, then not eligible)

Does organization provide any of the following to healthcare provides? Scientific, educational or professional programs, meetings or events, including, but not limited to the following: continuing medical education, disease awareness, and sponsorship of symposia at a medical conference.

YES NO

If yes, please provide details.

Does organization dedicate more than 25 percent of operating budget for patient advocacy?

YES NO (If yes, that more than 25 percent of operating budget is designated for patient advocacy, then not eligible)

Past GSK IMPACT Award Winner? YES NO If yes, then list year:

(If 2045 Winner, then not eligible)

Current GSK grantee? YES NO

(If 2015 calendar year GSK charitable grantee, then not eligible)



Organizational operating budget: Current year: $ ; Previous year: $

(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 organizational budget is less than $200,000 or more than $7.5 million, then not eligible)

Staff size:Full-time Part-time Volunteer

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 Foundation and Corporate Investors:

Number served annually: (Total population served)

(Actual number served through face-to-face interactions, not literature distribution)

Counties served:

(Must include Bucks, Chester, Delaware, Montgomery, and/or Philadelphia Counties in PA to be eligible)

Gender of those served: % female % male

Age: % pre-kindergarten % elementary age % middle school age

% high school age % adults % seniors/elders

Ethnicity: % Caucasian % Black or

African American % Latino or Hispanic



% Asian or Asian American

% Native American % Native Hawaiian/ Other Pacific Islander

% Other

Misc:

Poverty: % Percentage of population served that is below federal poverty guidelines

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: (Twitter, Facebook, Instagram, LinkedIn, etc)

Program Description

Please list and describe up to three programs that your nonprofit administers that you would like considered in


% Veteran % Physically Challenged

% Mentally Challenged

% Immigrants % Incarcerated % Substance Abuse

% Orphaned Children (have lost one or more parents)

% History of Domestic Violence

% Other; please specify:


your nomination for a GSK IMPACT Award. List the programs in order of priority. Note: If the purpose of the organization is the entirety of the program, then simply list the name of the organization as Program #1.

Please include which one of the following categories (factors that affect health) that your program addresses: 1- Diet and Exercise, 2- Education, 3- the Built Environment, 4- Employment, or 5- Family & Social Support.

For outcomes, please describe, with data, the most outstanding results achieved through this program(s). Ideally, the outcomes will cover achievements at the Individual, Organizational and Community-level. In other words, the outcomes should be related to the participants in the program (Individual), achievements within the organization (Organizational) and systemic improvements and reforms in the wider community (Community).

Example of an Individual-level outcome: For a Diet & Exercise program, an individual-level outcome could be “increased the percentage of youth participants (n=37 students) reporting they became physically active over a six month period of time from 12% in 2012 to 98% in 2013”. For an Education program, an individual-level outcome could be “increased the percentage of youth participants (n=45 students) who graduated from 45% to 85%.”

Example of an Organizational-level outcome: “Through the program, the organization established six new partnerships including two funders that have both made financial contributions and that has deepened sustainability of the organization” or “through the organization’s role as the Backbone Organization in the collective impact work of this collaborative program, the organization built capacity and is now serving in this role in two other collectives that are tackling other community health challenges.”

Example of an Community-level outcome: “Based in part on the success of this after school education program that helped 100% of participating students stay in school and earn their diploma, and based in part on this organization being a partner in the development of the county health plan, the county has increased funding and is scaling this program to all 15 public high schools in the district.”

Lead with the most outstanding primary program. Note: If the purpose of the organization is the entirety of the program, then simply list the name of the organization as Program #1.

Program #1 / Primary Program Title: Addresses the following Health Category: Mission (3 sentences or less): Percent of overall organization budget: %Total population served: Outcomes (include data):

Individual-level outcome(s): Organizational-level outcome(s): Community-level outcome(s):

Program #2: Addresses the following Health Category: Mission (3 sentences or less): Percent of overall organization budget: %Total population served: Outcomes (include data):

Individual-level outcome(s):





http://www.countyhealthrankings.org/health-factors/built-environment




Organizational-level outcome(s): Community-level outcome(s):

Program #3: Addresses the following Health Category: Mission (3 sentences or less): Percent of overall organization budget: %Total population served: Outcomes (include data):

Individual-level outcome(s): Organizational-level outcome(s): Community-level outcome(s):

IMPACT Criteria

Each application will be evaluated based on how well it demonstrates IMPACT - an acronym capturing the six guiding principles of the GSK IMPACT Awards: the organization must be: 1) “Innovative”, 2) “Measured”, 3) “Partnered”, 4) “Accountable”, 5) “Community-centered”, and 6) “Transformative”.

Criteria #1: Innovative (Vision, initiative, creativity, and leadership in solving pressing community health challenges.)

Summarize in no more than 150 words how the organization is innovative. Most competitive applications will demonstrate how vision, initiative, creativity, and leadership in the design, implementation, evaluation, and continuous improvement of the program(s) has set the organization apart from other nonprofits in the community and around the country and has contributed to better outcomes.

Criteria #2: Measured (Quantitative and qualitative data have informed the design, implementation, evaluation, and continuous improvement of the program(s) and demonstrates measurable outcomes.)

List the sources of data (for example, the County Health Rankings & Roadmaps or the county health assessment and plan such as Philadelphia County’s here) that contributed to the design, implementation, evaluation, and/or continuous improvement of the program(s) and explain how data were used:

Data Source #1, role, and describe: Data Source #2, role, and describe: Data Source #3, role, and describe:

Summarize in no more than 150 words how the organization is measured. Most competitive applications will demonstrate two things: 1) how data-informed lessons learned throughout the design, implementation, and evaluation of the program(s) have informed what the organization is or is not doing now; 2) how being measured and incorporating evidence-informed decision-making has contributed to better outcomes.


http://www.phila.gov/health/pdfs/CHAslides_11513.pdf

http://www.countyhealthrankings.org/


Criteria #3: Partnered(Meaningful collaboration across sectors, where possible, characterized by collective impact – a common agenda, shared measures, mutually reinforcing activities, continuous communication, and a backbone organization providing adaptive leadership.)

List the partner organizations for the program(s), including community-wide coalitions, and their respective roles and contributions. Most competitive applications will have partnerships across sectors and can demonstrate that the partnerships are not just informal relationships with occasional information-sharing, but rather formal collaborations with coordinated program delivery, resource sharing, and/or joint ventures. Also, the most competitive applications will demonstrate how these meaningful partnerships have contributed to better outcomes than if the organization were working alone.

Partner #1, role, and describe: Partner #2, role, and describe: Partner #3, role, and describe: Partner #4, role, and describe: Partner #5, role, and describe: Partner #6, role, and describe: Criteria #4: Accountable(Good governance, including sound financials, strategic leadership, strong management, and stable operations, which contribute to high-performing programs and overall accountability.)

Nonprofit organizations are responsible for safeguarding assets and serving charitable interests. High-performing nonprofit organizations – characterized by good governance, sound financials, strategic leadership, strong management, and stable operations – have comprehensive infrastructure in-place to ensure accountability. Please respond to the following questions. The most competitive applicants will demonstrate mature capacity across all aspects.

1) 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:

2) Check all that apply for the Board of Directors and indicate what percentage of your Board, where appropriate:

Women: % Immigrants: % Differently Abled: %

Caucasian: % Black/African American: % Latino or Hispanic: %

Native American: % Asian/Asian American: % Native Hawaiian/Other Pacific Isl: %

Other: %

3) 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)


http://www.ssireview.org/articles/entry/collective_impact


Current YearFY end date: (ex: June 30, 2014)

Previous YearFY end date: 2 Years Prior FY end date: 3 Years Prior FY end date:

If your organization has incurred any deficits in the past three years, then please explain and also verify whether or not the deficit exceeded 10% of operating budget:

4) Check all that apply for senior management and indicate what percentage, where appropriate:

Women: % Immigrants: % Differently Abled: %

Caucasian: % Black/African American: % Latino or Hispanic: %

Native American: % Asian/Asian American: % Native Hawaiian/Other Pacific Isl: %

Other: %

5) Summarize in no more than 150 words how the organization is accountable. Most competitive applications will demonstrate mature levels of infrastructure that ensure good governance and accountability.

Criteria #5: Community-centered(Inclusive, responsive, and adaptive to the changing needs and circumstances of the community.)

Summarize in no more than 150 words how the organization is community-centered. Most competitive applications will demonstrate how the input of the local community/and beneficiaries of the program(s) have been included in the design, implementation, evaluation, and continuous improvement of the program(s), and how this community-based input has contributed to better outcomes.

Criteria #6: Transformative(A component of the larger community health plan and influencing systemic reform, and being replicated and/or scaled.)

Summarize in no more than 150 words, how the organization is transformative. Most competitive applications will demonstrate that the program(s) is embraced by community leadership, is actively engaged in a community-wide coalition and/or a component of the larger community health plan, is influencing systemic policy reform and the program(s) is being replicated and/or taken to scale. If these elements have not yet occurred, then outline if and how it can be done.



How did you hear about the GSK IMPACT Awards? Check all that apply:

UWGPSNJ (email, website, social media, or word of mouth); please specify: GSK (email, website, social media, or word of mouth); please specify: Print media (Newspaper, magazine, etc.); please specify: Broadcast media (Radio, TV, etc.); please specify: From a former winner; please specify: Other; please specify:

For Past GSK IMPACT Award Winners Only:

In no more than 150 words, describe the substantial, positive change and/or significant development that has occurred in the program(s) since the previous award period.

(Optional) Please share your perspective on the connection between health and community. More specifically, from your experience, please briefly describe how program(s) such as those that improve the built environment, employment, or family & social support (factors that are not traditionally considered health-related) actually matter to our health and contribute to a healthier community.



Rules for GSK IMPACT Awards

1. No applications will be accepted after the closing date, which is Friday, May 22, 2015.2. 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 announced.

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 items #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.

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 http://www.gsk.com/policies/Prevention-of-Corruption-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


http://www.gsk.com/policies/Prevention-of-Corruption-Third-Party-Guidelines.pdf

http://www.gsk.com/policies/Prevention-of-Corruption-Third-Party-Guidelines.pdf


Print Name Title



Appendix

Examples of Healthcare Professionals

– Advanced Practice Nurse – Certified Diabetic Educator – Clinical Nurse Specialist – Dental Assistant – Dietitian – Doctor of Dental Surgery – Doctor of Medical Dentistry – Doctor of Medicine – Doctor of Naturopathic Medicine (ND) – Doctor of Optometry – Doctor of Osteopathy – Doctor of Pharmacy (PharmD) – Doctor of Philosophy (PhD) (limited to degrees that provide prescribing privileges) – Doctor of Podiatric Medicine – Doctor of Veterinary Medicine – Emergency Medical Technician – Formulary Administrator – Licensed Chiropractor – Licensed Clinical Social Worker – Licensed Practical Nurse – Licensed Psychologist – Medical Assistant (AMA)– Medical Student – Medical Technologist – Mental Health Assistant – Nurse Anesthetist – Nurse Midwife – Nurse Practitioner – Oncology Clinical Nurse – Registered Pharmacist (RPH)– Physical Therapist – Physician Assistant – Post Anesthesia Care Nurse – Registered Dental Hygienist – Registered Nurse – Respiratory Therapist – Any other person, providing health care or authorized to recommend or prescribe drugs – Officers, Agents, Employees or Contractors of HCP’s acting in the course and scope of employment providing

health care to individuals


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