(Items in *BOLD are Required)

Name*:

E-mail*:

Company / Organization*:

Address*:

City*:

State*:

Zip*:

Telephone*:

Fax:

Award Category*:

(please select one):
National:
To recognize a national organization whose activities reach multiple communities.

Local:
To recognize local community groups, hospitals, professional chapters and other entities whose efforts are targeted to a local or regional area.

Target Audience*:

Describe your program’s target audience

Program Reach*:

Number of people reached:



Explain how this number was determined/calculated:

Program Abstract*:

Please provide a summary of your program. Specify months/year(s) that program was implemented. (Maximum length is 300 words.)

Originality and Innovative Design*:

Describe how the program exhibits originality and/or innovative design. (Maximum length is 300 words.)

Implementation and Evaluation*:

Please provide details on how the program was implemented and evaluated. Be sure to include any objective data or results. (Maximum length is 300 words.)

Media Outreach:

If applicable, please describe efforts to extend your program’s reach through the media and include a summary of media placements. (Maximum length is 300 words.)

Use of Stay in Circulation Campaign Materials and Messages*:

Please describe how materials and/or messages from the Stay in Circulation campaign were utilized. (Maximum length is 300 words.)

Impact on Health Status, Clinician Behavior and/or Other Factors:

If applicable, please define efforts used to evaluate the program’s impact on health status, clinician behavior and/or other factors. What measures were developed to evaluate the program? How were outcomes tracked? (Maximum length is 300 words.)

Collaboration:

If applicable, please describe how your organization collaborated with other groups (i.e., health care agencies, community organizations, learning institutions, others interested in improving vascular health) on the implementation of this program. (Maximum length is 300 words.)