Date:
______________________________________________________________________________________________

Organization
Name:
__________________________________________________________________________________

Contact
Person:______________________________________________________________________________________

Title:
______________________________________________________________________________________________

Department:
________________________________________________________________________________________

Phone:
____________________________________________
Fax:
____________________________________________

E­
mail:
______________________________________________________________________________________________

Have
you
received
recognition
(
other
than
from
H2E)
for
your
environmental
initiatives?

Yes
No
My
organization
submits
this
application
for:

H2E
Partner
for
Change
Award
 
Annual
H2E
Making
Medicine
Mercury
Free
Award
 
One­
time
H2E
Environmental
Leadership
Award
 
Annual
H2E
Champion
for
Change
Award
 
Annual
Is
your
application
complete?
Have
you:

Reviewed
the
Award
Evaluation
Criteria?

Included
the
checklist
if
applying
for
the
Making
Medicine
Mercury
Free
Award?

Included
two
complete
copies
of
the
application
packet?

Submitted
supporting
materials?
Please
list:

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

Signature:
__________________________________________________________________________________________

Name
(
print
clearly):
__________________________________________________________________________________

Fax
application
to:
202­
234­
9121
or
Mail
application
to:
H2E
1755
S
Street
NW
Suite
6B
Washington
DC
20009
Phone:
800­
727­
4179
(
for
questions
about
awards
program)

Phone:
202­
234­
0091
extension
13
(
for
FedEx
and
other
deliveries
only)
2002
Awards
Application
Form
Timeline
for
2002
Award
Cycle
3/
1/
02
Applications
due
3/
15/
02
Announcement
of
award
recipients
4/
8/
02
Environmental
Leadership
Awards
Ceremony
at
the
AHA
annual
meeting
TBD
Making
Medicine
Mercury
Free
Awards
Ceremony
9/
22/
02
Partner
for
Change
Awards
Ceremony
at
the
ASHES
annual
meeting
See
reverse
page
for
awards
information.
Be
An
H2E
Winner!

Award
Categories
As
a
participant
in
the
Hospitals
for
a
Healthy
Environment
(
H2E)
program,
you
have
the
opportunity
to
apply
for
one
of
the
following
awards:


H2E
Partner
Recognition
is
given
to
facilities
that
have
pledged
to
be
H2E
partners
and
have
met
goals
they
have
set
for
their
facilities.
H2E
encourages
all
partners
to
set
goals
in
2002
to
receive
recognition
in
2003.


The
Making
Medicine
Mercury­
Free
Award
is
a
one­
time
award
given
to
facilities
that
have
met
the
challenge
of
becoming
"
mercury
free."


The
H2E
Partners
for
Change
Award
is
given
annually
to
facilities
that
have
made
significant
progress
reducing
waste,
preventing
pollution,
and
eliminating
mercury.


The
H2E
Environmental
Leadership
Award
is
the
premier
H2E
award
given
annually
to
facilities
that
have
active,
ongoing
waste
and
mercury­
use
reduction
programs
and
are
setting
the
industry
standard
for
environmental
policies
at
other
hospitals.


The
H2E
Champion
Award
recognizes
supporters'
efforts
to
promote
the
H2E
program
among
health
care
facilities,
to
recruit
new
H2E
partners,
and
to
support
and
promote
H2E
goals
within
their
own
organizations.

Award
Benefits
All
H2E
award
recipients
will
receive
the
following:


A
plaque

An
award
packet,
which
includes
a
press
release
and
official
letter
of
congratulations

Recognition
in
appropriate
journals,
newsletters
of
relevant
professional
organizations,
and
on
the
H2E
Web
site

Inclusion
on
the
list
of
facilities
across
the
country
that
are
setting
the
industry
standard
for
making
health
care
environmentally
responsible
Application
Process
1)
Select
an
awards
category
from
above.
Ensure
that
your
facility
is
eligible
by
consulting
the
evaluation
criteria
on
the
H2E
Web
site
at
<
www.
h2e­
online.
org/
programs/
awards.
htm>
or
contact
H2E
at
<
h2e@
erg.
com>
or
800­
727­
4179.
2)
Complete
the
application
form
on
the
reverse
side.
3)
Describe
how
your
facility
meets
the
evaluation
criteria
for
the
award.
Mercury­
Free
Medicine
Award
applicants
should
also
complete
and
submit
the
H2E
Making
Medicine
Mercury
Free
Checklist
found
at
<
www.
h2e­
online.
org/
pubs/
checklist.
pdf>.
4)
Submit
supporting
materials.
You
are
welcome
to
include
additional
materials
such
as
photographs,
newsletters,
fliers,
and
policies.
Please
list
those
supporting
materials
on
the
application
form.
Attachments
and
supporting
materials
will
not
be
returned.

Review
Process
H2E
will
be
select
winners
by
a
panel
of
representatives
from
government,
hospitals,
trade
associations,
non­
government
organizations,
and
technical
assistance
providers.
Once
decisions
are
made,
you
will
receive
notification
regarding
the
results
of
your
application.

Working
Together
to
Achieve
Healthy
Communities!
Visit
the
H2E
Web
site
at
<
www.
h2eonline
org/
programs/
awards.
htm>
for
more
detailed
information
on
awards.
