Champion
for
Change
Application
Champion
for
Change
Commitments
As
a
Champion,
your
organization
agrees
to
commit
to
the
following:

1.
Submit
a
list
of
measurable
objectives
on
an
annual
basis
that
demonstrates
how
your
organization
will
fulfill
the
goals
of
the
H2E
program.
Your
objectives
should
include
the
strategies
on
how
you
will
help
to
facilitate
progress
with
your
organization's
affiliated
health
care
facilities,
as
well
as
within
your
own
organization.

2.
Recruit
health
care
facilities
to
become
H2E
Partners
and
help
them
to
take
steps
to
meet
H2E
goals.

3.
Provide
your
affiliated
healthcare
facilities
with
ongoing
information
and
programmatic
support
to
make
measurable
improvements
in
their
mercury
elimination,
waste
minimization,
toxicity
reduction
and
pollution
prevention
programs.

4.
Design
and
implement
a
program
for
your
own
organization
to
reduce
its
environmental
impact.

5.
Provide
a
link
to
H2E
website
on
your
organization's
website
and
include
other
information
as
appropriate.

6.
Publicly
share
your
objectives
and
strategies
for
how
your
organization
is
going
to
help
meet
the
goals
of
H2E
goals.

Application
Process
1.
Complete
the
application
and
submit
electronically
to
H2E@
hcwh.
org.
Call
1­
800­
727­
4179
with
questions
or
for
more
information.

2.
An
H2E
representative
will
contact
you
to
discuss
your
application.

SECTION
1:
CONTACT
INFORMATION
Organization
Name:
________________________________________
Date:
__________

Contact
Name:
____________________________
Title:___________________________

Address:
________________________________________________________________

City:
______________________________
State:
_________________
Zip:
___________

Phone:
_____________________________
Fax:
________________________________

E­
mail:
_________________________
Website:
________________________________
(
Provide
URL
to
link
from
the
H2E
site)

Page
1
of
1
Champion
for
Change
Application
Approximate
number
of
health
care
facilities
associated
with
your
organization:
________

Type
of
Organization:
_____
Environmental
Organization
_____
Service
Provider
_____
Government
Agency
_____
Trade
Association
_____
Group
Purchasing
Organization
_____
Vendor
_____
Health
System
_____
Other,
specify:
_____
Regional/
National
Organizations
______________________________

*
Are
you
in
compliance
will
all
pertinent
OSHA
and
EPA
regulations?
____
Yes
____
No
____
N/
A
If
you
are
not
in
compliance,
please
describe
circumstances
of
non­
compliance:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

SECTION
2:
INTERNAL
ENVIRONMENTAL
COMMITMENTS
As
a
Champion
for
Change,
we
would
like
ensure
your
organization
has
made
internal
commitments
to
the
principles
of
H2E
by
implementing
internal
waste
reduction
and
pollution
prevention
projects.

For
example:

­
If
you
are
a
manufacturer
or
vendor,
are
you
providing
environmentally
preferable
alternatives,
do
you
minimize
or
recycle
materials
on
the
plant
floor,
have
you
considered
implementing
a
packaging
"
take­
back"
program
or
other
program
that
will
encourage
recycling
or
reuse,
do
you
have
a
commitment
to
use
less
toxic
products
or
packaging,
or
have
you
discontinued
the
use
or
sale
of
all
mercury­
containing
products
and
equipment?

­
If
you
are
a
service
provider,
professional/
trade
organization,
or
government
organization,
have
you
adopted
an
environmental
policy
statement
for
your
organization,
adopted
recycling
and
waste
reduction
programs
for
your
offices,
or
implemented
your
own
environmentally
preferable
purchasing
program?

1.
Please
indicate
if
your
organization
has,
or
plans
to
adopt
any
of
the
following
policies
or
programs.
Please
indicate
if
it
is
an
existing
or
planned
program
and
describe
your
organization's
specific
measurable
objectives
and
your
strategies
for
implementation
of
the
policy
or
program.

Page
2
of
2
Champion
for
Change
Application
1.
(
continued)

a.
Organizational
Environmental
Commitment
Statement
_____________________________________________________________________

_____________________________________________________________________

b.
Comprehensive
Waste
Management
Program­
including
recycling
_____________________________________________________________________

_____________________________________________________________________

c.
Mercury
Management/
Elimination
Program
_____________________________________________________________________

_____________________________________________________________________

d.
Environmentally
Preferable
Purchasing
Program
_____________________________________________________________________

_____________________________________________________________________

e.
Other
_____________________________________________________________________

_____________________________________________________________________

2.
Does
your
organization
use,
manufacture
or
distribute
any
mercury­
containing
items?

____
Yes
____
No
____
N/
A
If
yes,
do
you
have
a
labeling
or
identification
strategy?
____
Yes
____
No
Do
you
have
plans
to
phase
out
the
use,
manufacture,
or
distribution
of
these
items?

____
Yes
____
No
If
applicable,
please
describe:
_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Page
3
of
3
Champion
for
Change
Application
SECTION
3:
H2E
OBJECTIVES
AND
STRATEGIES
1.
Please
describe
why
your
organization
is
applying
to
become
an
H2E
Champion:

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

2.
Please
briefly
describe
your
organization's
specific
measurable
objectives
and
your
implementation
strategies
to
help
health
care
facilities
meet
each
objective
as
they
relate
to
H2E's
goals.

a.
Virtually
eliminating
mercury­
containing
waste
from
hospitals'
waste
streams
by
2005:

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

b.
Reducing
the
overall
volume
of
solid
waste
by
33
percent
by
2005
and
by
50
percent
by
2010:

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________
c.
Minimize,
eliminate
and/
or
improve
the
management
of
hazardous
chemicals
and
persistent,
bioaccumulative,
and
toxic
pollutants
in
healthcare:

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Page
4
of
4
Champion
for
Change
Application
d.
Other:

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

3.
How
will
your
organization
publicize
your
commitments
to
H2E,
the
changes
made
and
your
work
toward
toxicity
reduction
and
pollution
prevention
(
i.
e.,
outreach,
mailings,
conferences,
media
etc.)?

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

4.
How
many
of
your
facilities
or
members
of
your
trade
association
do
you
aim
to
have
pledge
in
the
coming
year?
_______

5.
How
will
your
organization
work
to
ensure
H2E
goals
are
adopted
and
implemented
by
affiliated
healthcare
facilities?

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Signature
of
Senior
Official
___________________________________________________

Print
Name
_______________________________________________________________

Title
________________________________________________
Date
_______________

Upon
completion,
please
mail
or
fax
this
form
to:

Hospitals
for
a
Healthy
Environment
1755
S
Street
NW,
Suite
6B
Washington,
DC
20009
Phone:
1­
800­
727­
4179
Fax:
202­
234­
9121
E­
mail:
H2E@
hcwh.
org
Page
5
of
5
