2013 Nomination Form

NIVS Immunization Excellence Awards
Nominations must be received by COB March 25, 2013.

The National Influenza Vaccine Summit (NIVS) is soliciting candidates for the 2013 NIVS Immunization Excellence Awards. The 2013 awards recognize individuals and organizations that have made extraordinary contributions towards improved adult, and/or childhood influenza vaccination rates within their communities during the 2012-2013 Influenza Season. This year we have also added an award recognizing immunization activites focused on the adult population, beyond influenza. . A National Winner and Honorable Mention recipient will be selected for each award category. The winners will be presented with their awards at the National Influenza Vaccine Summit meeting (to be held in May 14-16/Atlanta, GA). The national winner in each category will be invited to present their programs at the National Influenza Vaccine Summit meeting.

Award Information

Award Categories:   There are five categories of recognition:
·       Overall Flu Season Activities (activities related to early season and later season )
·       Healthcare Personnel Campaign (community or institutional-based activities, or both)
·       Immunization Coalitions / Public Health / Community Campaign (programs conducted within states and communities that demonstrate strong public and private collaboration)
·       Corporate Campaign (programs developed by communication / public relations organizations and/or supported by manufacturers, distributors or other for profit entities (like multi-practice site companies))

·       NEW: Overall Adult Immunization Activities - Beyond Flu (programs and activities focused on adult patient populations beyond influenza vaccination (may include flu activities but must go beyond those activites))

Note: the awards selection committee reserves the right to create additional categories or to not award any winners in a particular category.

Evaluation Criteria: Nominees will be evaluated in the following areas related to their immunization activities:
·         Collaboration: describe the extent of collaboration with other providers and/or organizations such as state and local professional organizations, local health departments, local hospitals, etc.

·         Originality: describe the creativity, innovation and originality utilized by the nominee in achieving the influenza vaccination rates in their community

·         Participation and Impact: describe the number and types of healthcare providers and other immunization stakeholders that participated in the activity, as well as the number and demographics of the patients who were vaccinated and/or received influenza immunization messages. Inclusion of number of individuals vaccinated or educated is encourged.

·         Challenges and Opportunities: describe the challenges and opportunities that the nominee encountered and how they addressed those issues.

Each Award Category recipient receives:

Category Winners

Category Honorable Mentions

·         Award plaque (one to individual or to project)

·         $1,000 Honoraria*

·        Travel, Lodging and Registration to National Influenza Vaccine Summit Meeting (up to $1,000) *

·         Presentation of Winning Project (limited to 15 minutes) at the National Influenza Vaccine Summit Meeting

·         News Release on receipt of Award

Corporate Category Recipients do not receive items indicated with an *

·         Framed Award Certificate (one to individual or to project)

·         $250 Honoraria*

·         Presentation of Award to recipient at the National Influenza Vaccine Summit Meeting

·         News Release on receipt of award

Corporate Category Recipients do not receive items indicated with an *

Nominations may be submitted online by completing the form below and clicking the submit button.

Direct inquiries or mail, fax or email completed forms to:

Mitchel C. Rothholz, RPh, MBA
c/o American Pharmacists Association
2012 NIVS Immunization Excellence Awards
101 Harvest Glenn Drive
Harleysville, PA 19438
1-800-237-APhA (2742) ext 7549 Direct: 202-429-7549 FAX: 202-429-6300
email: mrothholz@aphanet.org (prefered for scanned documents)

Nominee

Award Category Applying For:

Organization / Practice (if applicable):

First Name

MI

Last Name

Address 1

Address 2

City

State

Postal Code

Phone

Email Address

Individual Submitting Nominations

Self Nomination?

Yes (information above, - don't need to enter info again)

No (enter information below)

First Name

MI

Last Name

Address 1

Address 2

City

State

Postal Code

Phone

E-mail

Describe the candidate’s efforts to improve the vaccination rates within their communities. Why should they receive the award in this category? Include specific activities and accomplishments that support their nomination. The description placed in the below box will be reprinted in the program booklet.  Be sure to address the evaluation criteria below. (limit 750 words for the statement to be placed in the award booklet; Material samples (provide 5 copies), pictures accepted) (send additional sheets if needed to mrothholz@aphanet.org or to mailing address above with nomination name attached to document)

Statement for the awards booklet that describes the overall accomplishment of the nominee

Criteria 1: Collaboration: describe the extent of collaboration with other providers and/or organizations such as state and local professional organizations, local health departments, local hospitals, etc.

Criteria 2: Originality: describe the creativity, innovation and originality utilized by the nominee in achieving the vaccination rates in their community

Criteria 3:  Participation and Impact: describe the number and types of healthcare providers and other immunization stakeholders that participated in the activity, as well as the number and demographics of the patients who were vaccinated and/or received immunization messages. Inclusion of number of individuals vaccinated or educated is encourged.

Criteria 4: Challenges and Opportunities: describe the challenges and opportunities that the nominee encountered and how they addressed those issues.

We will be submitting additional supporting material by the deadline

Yes, via mail

Yes, via e-mail

Yes, via FAX

No

If you are a selected award recipient what newspaper(s) would you like the award winner news release sent to:

Indicates Response Required