GSK IMPACT Awards for the Triangle Region
Application 2017
GSK IMPACT Awards for the
Triangle Region
Application 2017
Registration Deadline:
Friday, April 7, 2017
Application Deadline:
Friday, May 5, 2017
Application Form
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Before completing this form, please review the GSK IMPACT Award 2017 Registration and Application Instructions
(Triangle Region) document in full to ensure that your organization is eligible and competitive for a GSK IMPACT
Award.
To complete the application, download a copy of this form to your own computer, and click in the gray box to begin
typing – boxes will expand automatically.
The application has five sections – 1) Organizational Information, 2) Financial Information, 3) Client Information, 4)
Application Questions, and 5) Detail on Program(s). All sections of the application must be completed.
The application must be signed and dated (final page) prior to submission – unsigned applications will not be
accepted.
Part 1: Organizational Information
Organization Name:
(Legal IRS Name)
Organization AKA Name:
(if applicable)
Is organization a 501(c)3?
Year organization received
501(c)(3) status:
YES
NO (If no, then not eligible)
Organization Overview/Mission:
(Ruling date):
EIN#:
State:
(Must be a 501(c)3 nonprofit organization)
Brief overview of organization (no more than three sentences)
Organization Category:
Please check the category(ies) for your organization (as many as apply):
Diet & Exercise
Education
Housing & Transit
Employment
Community Safety
Family & Social Support
Street address:
(street, city, state, zip)
County(ies) served:
(Must include at least one of the following counties to be eligible: Chatham,
Durham, Orange and/or Wake Counties in NC)
Executive Director:
(Name, title, office/cell phone, and
email)
Additional contact:
(Name, title, office/cell phone, and
email)
Organization Phone:
Organization Website:
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Application 2017
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Organization Social Media:
(List account handles or URL for all
that are applicable)
Twitter
Facebook
Instagram
LinkedIn
Other
Staff size:
Full-time
Part-time
Volunteer
Board of Directors – Check categories that apply and indicate percentage where applicable
Women:
%
Caucasian:
%
Native American:
Other:
Immigrants:
%
Black/African American:
%
Asian/Asian American:
Differently Abled:
%
%
%
Latino or Hispanic:
Native Hawaiian/
Other Pacific Isl:
%
%
%
Senior management – Check categories that apply and indicate percentage where applicable
Women:
%
Caucasian:
%
Native American:
Other:
Immigrants:
%
Black/African American:
%
Asian/Asian American:
Differently Abled:
%
%
%
Latino or Hispanic:
Native Hawaiian/
Other Pacific Isl:
%
%
%
Does your organization, as suggested by the IRS in Part VI, Section B of the Form 990, have:
1) conflict of interest policies; 2) whistleblower policy; 3) independent process with comparability data for determining
compensation; and does your organization 4) provide a copy of the 990 to board members prior to filing?
YES
NO; If no, then please explain:
Is organization a past GSK IMPACT
Award Winner?
Is organization a current GSK
grantee?
GSK IMPACT Awards for the Triangle Region
Application 2017
YES
NO
If yes, then list year:
(If 2015 or 2016 Winner, then not eligible)
YES
NO
(If 2017 calendar year GSK charitable grantee, then not eligible)
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Part 2: Financial Information
Organizational gross revenue:
Current fiscal year: $
; Previous fiscal year: $
Notes:
 Does not include in-kind donations
 Current year figures are based on board-approved budget forecasts;
previous year figures are based on the organization’s audited
statement of activities or completed 990.
 If gross revenue in current or previous fiscal year is less than
$160,000 or more than $5 million, then not eligible
Last Fiscal Year Support:
(actual or estimated)
Government
Fees/earned income
Individual donors
Foundations &
Corporations
Other (specify)
Totals
Amount
$
$
$
% of Budget
%
%
%
$
%
$
$
%
100%
List of top funders:
Complete the following chart with the financial information for the organization covering the current and
previous three years. Current year figures should be based on board-approved budget forecasts; three previous years
should be based on the audited statement of activities or completed 990. Most competitive applications will demonstrate
evidence of sound financial condition for three years or more.
Operating Budget /
Results
Current Year (Budget)
FY end date:
(ex: June 30, 2017)
Previous Year (Actual)
FY end date:
2 Years Prior (Actual)
FY end date:
3 Years Prior (Actual)
FY end date:
Revenue
Expense
Surplus/(Deficit)
If your organization has incurred any deficits in the past three years, then please explain and also verify
whether or not the deficit exceeded 10% of operating budget:
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Part 3: Client Information
Number served annually:
(Total population served)
Client location(s):
(county, city, neighbourhood, etc.)
Gender of those served:
% female
% male
% non-binary
% pre-kindergarten
% elementary age
% middle school age
% high school age
% adults
% seniors/elders
Age:
Ethnicity:
% Caucasian
% Asian or
Asian American
% Black or
African American
% Latino or
Hispanic
% Native American
% Native Hawaiian/
Other Pacific Islander
% Physically
Challenged
% Mentally
Challenged
% Other
Other:
% Veteran
% Immigrants
% Orphaned
Children (have lost
one or more parents)
% Incarcerated
% History of
Domestic Violence
% Substance Abuse
% Other;
please specify:
% Percentage of population served that is below federal poverty
guidelines
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Part 4: Application Questions
Summarize what your organization does and why it is worthy of a GSK IMPACT Award:
(250 words)
What is the community need(s) that your organization addresses and how does it affect health outcomes?
The GSK IMPACT Awards recognize local nonprofit organizations that are making communities healthier places to
live, learn, work and play, based on a model of population health called the County Health Rankings & Roadmap.
While many of these factors (1- Diet & Exercise, 2- Education, 3- Housing & Transit, 4- Employment, 5- Community
Safety or 6- Family & Social Support) are not traditionally thought of as health factors, competitive applications will
clearly articulate the connection between the community need(s) that your organization addresses and health
outcomes.
(150 words)
How does your organization address these community needs and why have you selected that approach?
(150 words)
How do you include, respond, and adapt to the community that your organization works with?
(150 words)
Please describe how your organization uses quantitative and qualitative data to inform the design,
implementation, evaluation, and continuous improvement of your program(s):
(150 words)
Please list up to five organizations that you partner with and describe how these meaningful partnerships
have contributed to better outcomes than if your organization were working alone:
(This question is intended to identify partners who have an active role in service provision, program implementation, or
broader community change. Please do not list funders unless they partner with your organization beyond funding.
You may list less than five.)
1.
2.
3.
4.
5.
Please describe how your organization demonstrates operational excellence:
(e.g. employee and Board development; sound governance; strategic planning; financial stability; volunteer support;
diverse and effective leadership; etc.)
(150 words)
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Please describe how your organization’s work is part of a larger movement to improve the health of the
community – this could include influencing systemic reform, engaging with regional or local planning efforts,
and/or your programs being replicated in other communities or scaled in your community:
(150 words)
Please share a lesson you have learned that you are using to improve the effectiveness of your organization:
(150 words)
Please share a success story that demonstrates how your work improves health outcomes an individual or
individuals in the community:
(250 words)
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Part 5: Detail on Program(s)
Please list and describe up to three programs that your organization administers that you would like
considered in your application for a GSK IMPACT Award. List the programs in order of priority.
In this section, please describe the social impact your programs have had on the community with a particular focus on
improving health outcomes. We are not only interested in understanding the numbers of individuals reached or
programming delivered, but also what impact you know (or believe) these interventions are having in the lives of
individual beneficiaries and/or the community at large.
For each measure, we will ask you to describe how you are capturing this data – this includes tracking (e.g. surveys or
other measurement tools), estimation (e.g. informed guesses by staff or inferred measures from other reports or
studies), or speculation (e.g. anecdotal evidence).
Notes:
 Please describe up to three relevant programs in the application – we expect the program descriptions to
represent a majority (or close to a majority) of the organization’s overall budget. For example, if you list only
one program and it represents just 10% of the overall budget, your application may not be competitive.
 If your organization runs only one program, then simply list the name of the organization as Program #1. You
do not need to complete Program #2 and #3.
 This section should describe current or past programs, not those that you plan to implement in the future.
Program #1 Title:
Addresses the following Health Category:
Percent of overall organization budget:
%
Program description:
(Suggested format – “We help [who] achieve [what successful outcome] through [summary of your services].”)
Describe intervention(s):
(In a single sentence per entry (up to four); identify each of the core services or activities your program uses to achieve
its goal.)
Note: This should be a high-level summary of your program’s intervention, not a detailed itemization of implementation
tasks.
1.
2.
3.
4.
Describe program reach and social impact:
(Please respond to questions 1 – 4 below)
1. How many people are served by this program?
(This response should be a number)
2. How are you measuring the number of people served by this program?
(This response should describe your means of measurement – examples include attendance logs, surveys,
public data, etc.)
3. Describe the social impact you aim to achieve in relation to this program – what is the state of
improved well-being that the people you work with achieve?
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(Examples include: number of people who are no longer overweight, reduced rates of violence, improved
safety or injury rates, increased social networks and supports, number of people housed, improved commute
times, etc.)
4. How are you measuring the social impact? In other words, how do know that your interventions are
having the desired effect?
(This response should describe your means of measurement – examples include surveys, pre- and post-tests,
focus groups, public data, etc. as well as the rationale for why this measurement points to your intended social
impact.)
Program #2 Title:
Addresses the following Health Category:
Percent of overall organization budget:
%
Program description:
(Suggested format – “We help [who] achieve [what successful outcome] through [summary of your services].”)
Describe intervention(s):
(In a single sentence per entry (up to four); identify each of the core services or activities your program uses to achieve
its goal.)
Note: This should be a high-level summary of your program’s intervention, not a detailed itemization of implementation
tasks.
1.
2.
3.
4.
Describe program reach and social impact:
(Please respond to questions 1 – 4 below)
1. How many people are served by this program?
(This response should be a number)
2. How are you measuring the number of people served by this program?
(This response should describe your means of measurement – examples include attendance logs, surveys,
public data, etc.)
3. Describe the social impact you aim to achieve in relation to this program – what is the state of
improved well-being that the people you work with achieve?
(Examples include: number of people who are no longer overweight, reduced rates of violence, improved
safety or injury rates, increased social networks and supports, number of people housed, improved commute
times, etc.)
4. How are you measuring the social impact? In other words, how do know that your interventions are
having the desired effect?
(This response should describe your means of measurement – examples include surveys, pre- and post-tests,
focus groups, public data, etc. as well as the rationale for why this measurement points to your intended social
impact.)
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Program #3 Title:
Addresses the following Health Category:
Percent of overall organization budget:
%
Program description:
(Suggested format – “We help [who] achieve [what successful outcome] through [summary of your services].”)
Describe intervention(s):
(In a single sentence per entry (up to four); identify each of the core services or activities your program uses to achieve
its goal.)
Note: This should be a high-level summary of your program’s intervention, not a detailed itemization of implementation
tasks.
1.
2.
3.
4.
Describe program reach and social impact:
(Please respond to questions 1 – 4 below)
1. How many people are served by this program?
(This response should be a number)
2. How are you measuring the number of people served by this program?
(This response should describe your means of measurement – examples include attendance logs, surveys,
public data, etc.)
3. Describe the social impact you aim to achieve in relation to this program – what is the state of
improved well-being that the people you work with achieve?
(Examples include: number of people who are no longer overweight, reduced rates of violence, improved
safety or injury rates, increased social networks and supports, number of people housed, improved commute
times, etc.)
4. How are you measuring the social impact? In other words, how do know that your interventions are
having the desired effect?
(This response should describe your means of measurement – examples include surveys, pre- and post-tests,
focus groups, public data, etc. as well as the rationale for why this measurement points to your intended social
impact.)
For Past GSK IMPACT Award Winners Only
Please describe the substantial, positive change and/or significant development that has occurred in the program(s)
since you received your GSK IMPACT Award:
(150 words)
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Rules for GSK IMPACT Awards
1. No applications will be accepted after the closing date, which is Friday, May 5, 2017.
2. Eligibility and awards are determined at the sole discretion of GSK. All decisions are final. Results of the judging will
be conveyed in writing to the organizations.
3. By submitting an application, your organization consents to the use of any information (including the right to use
your organization’s name, logo, or associated trademarks) provided in your application for publicity purposes
connected with the GSK IMPACT Awards. Applications submitted become the property of GSK and will not be
returned.
4. As a condition of receiving the award, your organization may be asked to agree to further terms and conditions after
the winners are selected.
5. GSK will produce high quality communication assets featuring the work of the winning organizations. For this
purpose, a photographer will visit the winning organizations to obtain photographs. In the event your organization is
selected as a winner, you hereby agree to execute a photographic release forms provided by GSK.
6. Award winners must provide a brief report to GSK on how they have benefited from the award and how it was used.
GSK may disseminate this information as a contribution to best practice.
7. GSK may use and publish the submissions referenced in items #6 above in connection with publicity of the awards.
GSK also may edit these submissions for editorial purposes (e.g. to conform to space requirements in distribution
platforms).
8. GSK will list our US Community Partnerships charitable contributions on our website. To that end, US Community
Partnerships charitable contributions will be given under the condition that the recipient organization consents to
public disclosure. Details disclosed may include but are not limited to the recipient organization's name, the award
purpose, and the amount of the award.
9. U.S. Community Partnerships charitable awards are not made and cannot be used to influence or promote the use
of GSK products.
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I certify I am the duly authorized officer or representative of the requesting organization and to the best of my
knowledge, the information provided in this application is accurate. I understand and agree to provide additional
documentation in support of the information provided if requested by GSK. (Representative must check box or
application will not be valid)
Additionally, if given a GSK IMPACT Award, the requesting 501(c)(3) organization must be willing to read GSK’s
‘Prevention of Corruption – Third Party Guidelines’ (at http://www.gsk.com/policies/Prevention-of-Corruption-ThirdParty-Guidelines.pdf) and agree to perform its obligations under the Agreement in accordance with the principles set
out therein.
By signing and submitting this Application Form, I confirm my organization’s understanding and acceptance of the
rules and conditions for application. The information in this Application Form is true to the best of my knowledge.
Signature of CEO / Executive Director or
Chief Financial Officer
Date
Print Name
Title
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Application 2017
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