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GSK IMPACT Awards for the Triangle RegionApplication 2016

Registration Deadline: Friday, March 25, 2016

Application Deadline: Friday, April 15, 2016

Table of contents

Application Form 2Part I: Executive Summary 2Part II: Program Detail 6Part III: Demonstrating IMPACT 11Rules for GSK IMPACT Awards 15Signature page 16



Application Form

Before completing this form, please review the GSK IMPACT Award 2016 Registration and Application Instructions (Triangle Region) 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 (Triangle Region) – 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: Enter the appropriate category for your organization – you may list one primary and up to two secondary categories: 1- Diet & Exercise, 2- Education, 3- Housing & Transit, 4- Employment, 5- Community Safety or 6- Family & Social Support

Primary Category Secondary Categories (if relevant)

Making the CaseIn no more than 500 words, summarize why your organization and programs are worthy of a GSK IMPACT Award.

Please describe: The community need your organization has addressed A description of your primary beneficiaries A summary of your organization’s response to this community need – including what actions you’ve

taken and what impact they’ve had on improving health outcomes in the community And finally, the lessons you have learned that inform your current programming

GSK IMPACT Awards for the Triangle RegionApplication 2016 2

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

http://www.countyhealthrankings.org/our-approach/health-factors/community-safety

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://us.gsk.com/media/590307/gsk-impact-award-2016-registration-and-application-instructions-triangle-region-final.pdf

http://us.gsk.com/media/590307/gsk-impact-award-2016-registration-and-application-instructions-triangle-region-final.pdf


Physical address (street, city, state, zip)

County location

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 GSK customer or affiliate of a GSK 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 professionals? 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 2015 Winner, then not eligible)

Current GSK grantee? YES NO

(If 2016 calendar year GSK charitable grantee, then not eligible)

Organizational gross revenue: Current fiscal year: $ ; Previous fiscal year: $

(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 gross revenue is less than $200,000 or more than $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 donors/investors:

Number served annually: (Total population served)

Counties served:

(Must include Chatham, Durham, Orange, and/or Wake Counties in NC 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)


% Veteran % Physically Challenged

% Mentally Challenged

% Immigrants % Incarcerated % Substance Abuse

% Orphaned Children (have lost one or more parents)

% History of Domestic Violence

% Other; please specify:


Part II: Program DetailProgram Description(s)

Please list and describe up to three programs that your nonprofit administers that you would like considered in your application for a GSK IMPACT Award. List the programs in order of priority.

Note: 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.

Note: If the 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.

Note: This section should describe current programs, not those that you plan to implement in the future.

Please include which one of the following health categories (factors that impact health) that your program addresses: 1- Diet & Exercise, 2- Education, 3- Housing & Transit, 4- Employment, 5- Community Safety or 6- Family & Social Support.

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 beneficiaries and/or the community at large.

We recommend that you review the County Health Rankings & Roadmap health factor descriptions (linked above) in order to familiarize yourself with the county-level measurements that Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute use to measure health factors. We do not expect applicants to use the same measures, but will be looking for evidence that your programs are working towards similar goals in each category to demonstrate a link to health outcomes.

For each program, we will ask you to explain how it generates value. This logic model (or “theory of change”) should briefly summarize your:

Intervention (i.e., what services your program delivers) Beneficiaries (i.e., who your program is designed to help) Outcomes (i.e., what are considered successful results)

The prompts below will help you to complete each component of your logic model.

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).

Program #1 / Program Title:

Addresses the following Health Category (see above): 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.

Identify beneficiaries: Please characterize the people your program is designed to serve by location and demographic category.

Beneficiary location(s): Beneficiary demographics and description:

Define indicators and report results: Describe your success measures.

1. (Optional) Capacity developed: Please describe any activities your organization leads or participates in that are increasing the capacity of the community to achieve improved health outcomes:[Examples include: policies or action plans implemented, practices or resources shared, partnerships developed, leaders or advocates developed, etc.]

2. (Required) Program reach: How many people are served by this program?

How are you measuring this indicator? Tracking/Estimation/Speculation – please describe

3. (Required) Program preparation: How many people served by this program gain the capacity to achieve the program’s purpose?

How would you describe ‘gaining capacity’ in relation to this program? [Examples include: gaining skills, awareness, motivation, or access to resources to increase healthy behavior, etc.] How are you measuring this indicator? Tracking/Estimation/Speculation – please describe

4. (Required) Program mobilization: How many people served by this program take the necessary action towards achieving the program’s purpose?

How would you describe ‘taking necessary action’ in relation to this program?[Examples include: Increasing physical activity, increasing consumption of fruits and vegetables, use of community spaces, utilizing transit, utilizing housing stabilization services, improve school performance, participate in paid internship, utilizing family support services, etc.] How are you measuring this indicator? Tracking/Estimation/Speculation – please describe



5. (Required) Social impact: How many people achieve a state of improved wellbeing?

How would you describe the desired ‘state of improved wellbeing’ in relation to this program?[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.] How are you measuring this indicator? Tracking/Estimation/Speculation – please describe

(Optional) Program #2 / Program Title:




1. 2. 3. 4.







3. (Required) Program preparation: How many people served by this program gain the capacity to



achieve the program’s purpose?





How would you describe the desired ‘state of improved wellbeing’ in relation to this program?[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.] How are you measuring this indicator? Tracking/Estimation/Speculation – please describe

(Optional) Program #3 / Program Title:




1. 2. 3.



4.







3. (Required) Program preparation: How many people served by this program gain the capacity to achieve the program’s purpose?





How would you describe the desired ‘state of improved wellbeing’ in relation to this program?[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.]




*Program description and logic model derived from True Impact LLC grant evaluation tool.


http://www.trueimpact.com/


Part III: Demonstrating IMPACT Demonstrating IMPACT

Each application will be evaluated based on how well it demonstrates the organization’s contribution to building a healthier community as well as ‘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”.

Impact on health outcomes

The GSK IMPACT Awards recognize local nonprofit 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. However, many of the factors that we focus on for the GSK IMPACT Awards program (1- Diet & Exercise, 2- Education, 3- Housing & Transit, 4- Employment, 5- Community Safety or 6- Family & Social Support) are not traditionally thought of as health factors.

Please share your perspective on the connection between health and community and how your programs actually matter and contribute to building a healthier community.

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”.

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.

2. Measured (Quantitative and qualitative data have informed the design, implementation, evaluation, and continuous improvement of the program(s) and demonstrates measurable outcomes. In addition to the response below, this criterion will be assessed based on the program indicators you’ve listed in Part II: Program Detail)

Summarize in no more than 150 words how the organization uses measurement and evaluation. Most competitive applications will demonstrate how data inform your approach and are effectively applied to influence the design, implementation, and continuous improvement of your programs.

3. Partnered(Meaningful collaboration within and across sectors)









http://www.countyhealthrankings.org/our-approach

http://www.countyhealthrankings.org/our-approach


List the partner organizations for the program(s), including community-wide coalitions, and their respective roles and contributions. Most competitive applications will have partnerships within and 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.

Note: Funders should not be listed as partners unless their contributions to the organization or program go beyond funding.

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:

4. Accountable(Good governance, including sound financials, strategic and diverse 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 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)

Current YearFY end date: (ex: June 30, 2015)

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.

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.



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.

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

Triangle Community Foundation (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.



Rules for GSK IMPACT Awards

1. No applications will be accepted after the closing date, which is Friday, April 15, 2016.2. 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 forms 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


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