Please indicate if any additional email address should be cc’ed on related correspondence
1. Problem Statement (max. 300 words)
2. Description (max. 300 words)
3. i) Implementation (max. 300 words)
3. ii) Timeline (max. 200 words)
4. Impact (max. 600 words)
i) Quantitative: Explain the impact of the innovation in terms of people reached, measurable improvements in health or quality of life, etc., as applicable to your innovation. Please be as specific as possible in providing evidence that supports any claims of impact. For example, instead of writing “we have seen a positive impact in terms of health outcomes,” please indicate which specific outcomes you measured and how those changed after project implementation.
ii) Qualitative: If possible, please provide testimonials from those who have benefited from your innovation or other specific examples of how it has helped.
*If needed, please include supporting documents (e.g., graphs or data) as part of your supplemental materials (see question 10).
5. Innovativeness (max. 200 words)
6. Reason For Success (max. 300 words)
Please describe the principles and factors that have contributed to the innovation’s success.
—In responding, please think about lessons that others might learn from your innovation.
7. Budget & Sustainability (max. 300 words)
Please provide a brief outline of the budget and the funding sources for the innovation.
—Programs/services: indicate the annual operating costs of the innovation and the sources of funding and whether it is financially sustainable (e.g., is the program fee-based, funded through grants, supported by the government, etc.?)
—Products: What is the cost or fee structure for the product?
—If appropriate, applicants may submit a simple budget to illustrate income and expenditures specifically related to the innovation (budget can be submitted as an attachment; please see question 8 on the next page to upload any budget attachments)
8. Further Information About the Applicant (max. 200 words)
9. Organization Roles (For projects that involve more than one organization)
If more than one organization is listed for the innovation, please briefly describe the role each organization plays in the project.
——Please note that in the event a group’s innovation is selected as the Grand Prize Winner, only one trophy will be provided to the group, although we will provide certificates to all organizations involved. At that time, you will need to indicate a name for the group that can be listed on the trophy and advertising materials, and indicate to which organization the trophy should be presented.
10. Supporting Materials
Applicants are welcome to submit materials that will assist us in evaluating the innovation. Please submit no more than 10 pages total as supplementary materials. Materials in excess of this amount may not be considered by the committee.
* Clearly note the name of the nominated innovation on any submissions.
—Supplementary materials may include, but are not limited to, the following: websites, photographs, print materials (brochures, fact sheets, flyers, etc.).
—We encourage applicants to submit supplementary materials that are in English. We will look at materials submitted in other languages, but will not be able to translate those materials or evaluate their written content.
—You may include supporting materials at the time of your submission of this form to firstname.lastname@example.org
Please note that the deadline to submit your application has been extended to May 31, 2022
You should receive a confirmation email automatically after you submit your application. If you have not received a confirmation email within 24 hours, please contact the secretariat via email (email@example.com).