FINAL_HCS_SSB_ATTACH 2_NOMINATION FORM_Jan 2013

FINAL_HCS_SSB_ATTACH 2_NOMINATION FORM_Jan 2013.xlsx

The Healthy Communities Study: How Communities Shape Childrens Health (NHLBI)

FINAL_HCS_SSB_ATTACH 2_NOMINATION FORM_Jan 2013

OMB: 0925-0649

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Overview

Nomination_Form
Reference


Sheet 1: Nomination_Form

SSB Attachment 2
INSTRUCTIONS: Please consider for certainty community nominations those communities that you would characterize as highly active over the past decade (2001 - 2011) in addressing obesity or obesity-related factors (e.g., diet and physical activity) among children and youth. For the purposes of the Healthy Communities Study, a “community” is the geographic equivalent of a public high school catchment area. However, you may nominate communities at different levels of geographic specificity (e.g., city, neighborhood, county). Please provide information about obesity-related programs and/or policies in this community in the appropriate spaces below.
NOMINATED COMMUNITY
1a Community Name <Enter text>
1b How would you characterize this community geographically?
Other:
1c Community Location: County
1d Community Location: State/U.S. Territory
1e Please provide a few sentences about why you believe this community merits inclusion in the HCS <Enter text>
PROGRAM INFORMATION
INSTRUCTIONS: Please provide the following details about any program(s) addressing obesity or obesity-related factors in the nominated community. If you would like to describe more than 10 programs, please insert additional rows below item "2j".
2 Program Name Funding Organization/Sponsor Funding Amount Duration of Program (including year ended, if applicable) Geographic Area Targeted by Program (e.g., Entire Community, Other - if Other, please describe) Links/Public Documents with More Information about Program
2a

<Enter a dollar amount>

<Enter references>
2b

<Enter a dollar amount>

<Enter references>
2c

<Enter a dollar amount>

<Enter references>
2d

<Enter a dollar amount>

<Enter references>
2e

<Enter a dollar amount>

<Enter references>
2f

<Enter a dollar amount>

<Enter references>
2g

<Enter a dollar amount>

<Enter references>
2h

<Enter a dollar amount>

<Enter references>
2i

<Enter a dollar amount>

<Enter references>
2j

<Enter a dollar amount>

<Enter references>
POLICY INFORMATION
INSTRUCTIONS: Please provide the following details about policies addressing obesity or obesity-related factors in the nominated community. If you would like to describe more than 10 policies, please insert additional rows below item "3j".
3 Policy Name Implementing Organization Duration of Policy (including year ended, if applicable) Geographic Area Targeted by Policy (e.g., Entire Community, Other - if Other, please describe) Links/Public Documents with More Information about Policy
3a



<Enter references>
3b



<Enter references>
3c



<Enter references>
3d



<Enter references>
3e



<Enter references>
3f



<Enter references>
3g



<Enter references>
3h



<Enter references>
3i



<Enter references>
3j



<Enter references>
NOMINATOR CONTACT INFORMATION
4a Name:
4b Organization:
4c Address:
4d City:
4e State:
4f Phone:
4g Email:

Sheet 2: Reference

<Select State>
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
U.S. Virgin Islands
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
File Typeapplication/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Modified0000-00-00
File Created0000-00-00

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