MBNQA Application & Checklist

This document contains the Eligibility Certification Form and checklist for the 2017 Malcolm Baldrige National Quality Award. Before filling out the form, please see Is Your Organization Eligible? (http://www.nist.gov/baldrige/enter/eligible.cfm) on our website.

The form uses text fields (     ) that expand as you type. To enter text, place your cursor in the field, click to highlight the field, and begin typing. Use the Tab key to navigate to the next field.

Paperwork Reduction Act Statement

This collection of information contains Paperwork Reduction Act (PRA) requirements approved by the Office of Management and Budget (OMB). Notwithstanding any other provisions of the law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply with, a collection of information subject to the requirements of the PRA unless that collection of information displays a currently valid OMB control number. Public reporting burden for this collection is estimated to be 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed and completing and reviewing the collection of information. Send comments regarding this burden estimate or any aspect of this collection of information, including suggestions for reducing this burden, to the National Institute of Standards and Technology, Attn: Robert Fangmeyer, Director Baldrige Program, robert.fangmeyer@nist.gov.

OMB Control No. 0693-0006

Expiration Date: 05/31/2016

1. Your Organization

Official name	     	Headquarters address	     
Other name	     
Prior name	(if changed within the past 5 years)      

2. Highest-Ranking Official

Mr. Mrs. Ms. Dr.

Name	     	Address	Same as above      
Job title	     
E-mail	     
Telephone	     
Fax	     

3. Eligibility Contact Point

Designate a person who can answer inquiries about your organization. Questions from your organization and requests from the Baldrige Program will be limited to this person and the alternate identified below.

Mr. Mrs. Ms. Dr.

Name	     	Address	Same as above
Job title	     		     
E-mail	     
Telephone	     	Overnight mailing address	Same as above (Do not use a P.O. box number.)      
Fax	     

4. Alternate Eligibility Contact Point

Mr. Mrs. Ms. Dr.

Name	     	Telephone	     
E-mail	     	Fax	     

5. Application History

1. Has your organization previously submitted an eligibility certification package?

Yes. Indicate the year(s). Also indicate the organization’s name at that time, if different.

Year(s)	     
Name(s)	     

No

Don’t know

2. Has your organization ever received the Malcolm Baldrige National Quality Award^®?

Yes.

Did your organization receive the award in 2011 or earlier?

Yes. Your organization is eligible to apply for the award.

No. If your organization received an award between 2012 and 2016, it is eligible to apply for feedback only. Contact the Baldrige Program at (877) 237-9064, option 3, if you have questions.

No

3. Has your organization participated in a regional/state/local or sector-specific Baldrige-based award process?

Yes. Years:

     

No

4. Is your organization submitting additional materials (i.e., a completed Organizational Profile and two results measures for each of the five Criteria results items) as a means of establishing eligibility?

No. Proceed to question 6.

Yes. In the box below, briefly explain the reason your organization chose this eligibility option. (This information will be shared with the Alliance leadership, without revealing your organization’s identity.)

     

6. Eligibility Determination

See also Is Your Organization Eligible? (http://www.nist.gov/baldrige/enter/eligible.cfm).

1. Is your organization a distinct organization or business unit headquartered in the United States?

Yes No Briefly explain.

     

2. Has your organization officially or legally existed for at least one year, or since April 1, 2016?

Yes No

3. Can your organization respond to all seven Baldrige Criteria categories? Specifically, does your organization have processes and related results for its unique operations, products, and/or services? For example, does it have an independent leadership system to set and deploy its vision, values, strategy, and action plans? Does it have approaches for engaging customers and the workforce, as well as for tracking and using data on the effectiveness of these approaches?

Yes No

4. If some of your organization’s activities are performed outside the United States or its territories and your organization receives a site visit, will you make available sufficient personnel, documentation, and facilities in the United States or its territories to allow a full examination of your worldwide organization?

Yes No Not applicable

5. If your organization receives an award, can it make sufficient personnel and documentation available to share its practices at the Quest for Excellence^® Conference and at your organization’s U.S. facilities?

Yes No

If you checked “No” for 6a, 6b, 6c, 6d, or 6e, call the Baldrige Program at (877) 237-9064, option 3.

Questions for Subunits Only

6. Is your organization a subunit in education or health care?

Yes. Check your eligibility by reading Is Your Organization Eligible?
(http://www.nist.gov/baldrige/enter/eligible.cfm). Then proceed to item 6k.

No. Continue with 6g.

7. Does your subunit function independently and as a discrete entity, with substantial authority to make key administrative and operational decisions? (It may receive policy direction and oversight from the parent organization.)

Yes. Continue with 6h.

No. Your subunit probably is not eligible to apply for the award. Call the Baldrige Program at (877)
237-9064, option 3.

8. Does your subunit have a clear definition of "organization" reflected in its literature? Does it function as a business or operational entity, not as activities assembled to write an award application?

 Yes. Continue with 6i.

No. Your subunit probably is not eligible to apply for the award. Call the Baldrige Program at (877)
237-9064, option 3.

9. Is your subunit in manufacturing or service?

 Yes. Does it have 500 or fewer employees? Is it separately incorporated and distinct from the parent
organization’s other subunits? Or was it independent before being acquired by the parent, and does it continue
to operate independently under its own identity?

Yes. Your subunit is eligible in the small business category. Attach relevant portions of a supporting official document (e.g., articles of incorporation) to this form. Proceed to item 6k.

No. Continue with 6j.

10. Is your subunit self-sufficient enough to be examined in all seven categories of the Criteria?

• Does it have its own senior leaders?

• Does it plan and implement its own strategy?

• Does it serve identifiable customers either inside or outside the organization?

• Is it responsible for measuring its performance and managing knowledge and information?

• Does it manage its own workforce?

• Does it manage its own work processes and other aspects of its operations?

• Can it report results related to these areas?

Yes. Proceed to 6k (table below).

No. Your organization probably is not eligible to apply for the award. Call the Baldrige Program at (877) 237-9064, option 3.

k. Does your organization meet one of the following conditions?

1. My organization has won the Baldrige Award (prior to 2012).	Yes	Your organization is eligible.	No	Continue with statement 2.
2. Between2012 and 2016, my organization applied for the national Baldrige Award, and the total of the process and results band numbers assigned in the feedback report was 8 or higher.	Yes	Your organization is eligible. Year:       Total of band scores:      	No	Continue with statement 4.
3. Between2012 and 2016, my organization applied for the national Baldrige Award and received a site visit.	Yes	Your organization is eligible. Year of site visit:      	No	Continue with statement 5.
4. Between2012 and 2016, my organization received the top award from an award program that is a member of the Alliance for Performance Excellence.	Yes	Your organization is eligible. Award program:       Year of top award:      	No	Continue with statement 3.
5. More than 25% of my organization's workforce is located outside the organization’s home state.	Yes	Your organization is eligible.	No	Continue with statement 6.
6. There is no Alliance for Performance Excellence award program available for my organization.	Yes	Your organization is eligible.	No	Continue with statement 7.
7. My organization will submit additional eligibility screening materials (i.e., a complete Organizational Profile and two results measures for each of the five Criteria results items). The Baldrige Program will use the materials to determine if my organization is eligible to apply for the award this year (as described in the fact sheet at www.nist.gov/baldrige/publications/upload/2015-Baldrige-Eligibility-FAQs.docx).	Yes	The Baldrige Program will review the materials and contact your ECP after determining your eligibility.	No	Call 877-237-9064, option 3, if you have questions.

7. Award Category

1. Award category (Check one.)

Your education or health care organization may use the Business/Nonprofit Criteria and apply in the service, small business, or nonprofit category. However, you probably will find the sector-specific (Education or Health Care) Criteria more appropriate.

For-Profit	Nonprofit
Manufacturing Service Small business (≤ 500 employees) Education Health care	Nonprofit Education Health care

2. Industrial classifications. In table below, list up to three of the most descriptive NAICS codes for your organization (see NAICS list included at the end of this document). These are used to identify your organizational functions and to assign applications to examiners.

     

     

     

8. Organizational Structure

1. For the preceding fiscal year, the organization had in

up to $1 million $1.1 million–$10 million $10.1 million–$100 million $100.1 million –$500 million $500.1 million–$1 billion more than $1 billion

sales revenue budget

2. Attach a line-and-box organization chart that includes divisions or unit levels. In each box, include the name of the unit or division and the name of its leader. Do not use shading or color in the boxes.

The chart is attached.

3. The organization is _____ a larger parent or system. (Check all that apply.)

not a subunit of (See item 6 above.) a subsidiary of controlled by administered by owned by

a division of a unit of a school of other __     ___

Parent organization	     	Address	     
Total number of paid employees*	     
Highest-ranking official	     	Job title	     
Telephone	     
*Paid employees include permanent, part-time, temporary, and telecommuting employees, as well as contract employees supervised by the organization. Include employees of subunits but not of joint ventures.

Attach a line-and-box organization chart(s) showing your organization’s relationship to the parent’s highest management level, including all intervening levels. In each box, include the name of the unit or division and its leader. Do not use shading or color in the boxes.

The chart is attached.

4. Considering the organization chart, briefly describe below how your organization relates to the parent and its other subunits in terms of products, services, and management structure.

        

   
   

5. Provide the title and date of an official document (e.g., an annual report, organizational literature, a press release) that clearly defines your organization as a discrete entity.

Title

     

Date

     

Attach a copy of relevant portions of the document. If you name a website as documentation, print and attach the relevant pages, providing the name only (not the URL) of the website.

Relevant portions of the document are attached.

6. Briefly describe the major functions your parent or its other subunits provide to your organization, if appropriate. Examples are strategic planning, business acquisition, research and development, facilities management, data gathering and analysis, human resource services, legal services, finance or accounting, sales/marketing, supply chain management, global expansion, information and knowledge management, education/training programs, information systems and technology services, curriculum and instruction, and academic program coordination/development.

     

9. Supplemental Sections

The organization has (a) a single performance system that supports all of its product and/or service lines and (b) products or services that are essentially similar in terms of customers/users, technology, workforce or employee types, and planning.

Yes. Proceed to item 10.

No. Your organization may need to submit one or more supplemental sections with its application. Call the Baldrige Program at (877) 237-9064, option 3.

10. Application Format

If your organization applies for the 2017 award, in which format will you submit your application?

25 paper copies and a CD (must be postmarked on or before May 10, 2017)

CD only (must be postmarked on or before April26,2017)

11. Use of Cell Phones, Cordless Phones, and Voice-over-Internet Protocol (VoIP)

Do you authorize Baldrige examiners to use cell phones, cordless phones, and VoIP to discuss your application? Your answer will not affect your organization’s eligibility. Examiners will hold all your information in strict confidence and will discuss your application only with other assigned examiners and with Baldrige Program representatives as needed.

Yes No

12. Site Listing

You may attach or continue your site listing on a separate page as long as you include all the information requested here. You may group sites by function or location (city, state), as appropriate. Please include the total for each column (sites, employees/faculty/staff, volunteers, and products/services). See the ABC HealthCare example below.

Please include a detailed listing showing all your sites. If your organization receives a site visit, an examiner team will use this information for planning and conducting its visit. Although site visits are not conducted at facilities outside the United States or its territories, these facilities may be contacted by teleconference or videoconference.

Example
	Sites (U.S. and Foreign) List the city and the state or country.	Workforce* List the numbers at each site.		List the % at each site, or use “N/A” (not applicable).
		Check one or more.  Employees  Faculty  Staff	Volunteers (no. or N/A)	Check one. % of  Sales  Revenue  Budget	Relevant Products, Services, and/or Technologies
	ABC Medical Center, Anytown, NY	1,232	147	77%	Admin. offices, inpatient care, ED, imaging services, lab
	ABC Hospital West, West Anytown, NY	255	78	14%	Inpatient services, ED, lab
	ABC Medical Group, Anytown, NY	236	N/A	6%	Primary & specialty physician care
	ABC Imaging Center, West Anytown, NY	11	N/A	1%	Imaging services
	ABC Hospice Services, West Anytown, NY	94	89	1%	On- and off-site hospice services
	ABC Urgent Care, West Anytown, NY	8	N/A	1%	Outpatient emergency and urgent care services
Total	6	1,836	314	100%

*“Workforce” refers to all people actively involved in accomplishing the work of your organization, including paid employees (e.g., permanent, part-time, temporary, and telecommuting employees, as well as contract employees supervised by the organization) and volunteers, as appropriate. The workforce includes team leaders, supervisors, and managers at all levels.

Your Organization
	Sites (U.S. and Foreign) List the city and the state or country.	Workforce* List the numbers at each site.		List the % at each site, or use “N/A” (not applicable).
		Check one or more. Employees Faculty Staff	Volunteers (no. or N/A)	Check one. % of Sales Revenue Budget	Relevant Products, Services, and/or Technologies
	     	     	     	     
	     	     	     	     
	     	     	     	     
	     	     	     	     
	     	     	     	     
	     	     	     	     
	     	     	     	     
	     	     	     	     
	     	     	     	     
	     	     	     	     
Total	     	     	     	100%

*The term workforce refers to all people actively involved in accomplishing the work of an organization. The workforce includes paid employees (e.g., permanent, part-time, temporary, telecommuting, and contract employees supervised by the organization) and volunteers, as appropriate; it also includes team leaders, supervisors, and managers at all levels.

13. Key Business/Organization Factors

List or briefly describe where necessary the following key business/organization factors (we recommend using bullets). Please be concise, but be as specific as possible. Provide full names of organizations (i.e., do not use acronyms). The Baldrige Program uses this information to avoid conflicts of interest when assigning examiners to your application. Examiners also use this information in their evaluations.

1. Main products and/or services and major markets served (local, regional, national, and international)

     

2. Key competitors (those that constitute 5 percent or more of your competitors)

        

3. Key customers/users (those that constitute 5 percent or more of your customers/users)

        

4. Key suppliers/partners (those that constitute 5 percent or more of your suppliers/partners)

        

5. Financial auditor Fiscal year (e.g., October 1–September 30)

        

        

6. Parent organization (if your organization is a subunit).

     

     

14. Nomination to the Board of Examiners

If your organization is eligible to apply for the Baldrige Award in2017, you may nominate one senior member from your organization to the 2017 Board of Examiners.

Nominees are appointed for one year only. Nominees

• must not have served previously on the Board of Examiners and

• must be citizens of the United States, be located in the United States or its territories, and be employees of the applicant organization.

The program limits the number of examiners from any one organization. If your organization already has representatives on the board, nominating an additional person may affect their reappointment.

Board appointments provide a significant opportunity for your organization to learn about the Criteria and the evaluation process. The time commitment is also substantial: examiners commit to a minimum of 110 hours from April to December, including approximately 40 hours in April/May to complete self-study, three to four days in May to attend Examiner Preparation, and 40–60 hours from June through August to complete an Independent and Consensus Review. If requested by the program, examiners also participate in a Site Visit Review of approximately nine days. The nominee or the organization must cover travel and housing expenses incurred for Examiner Preparation.

Mr. Mrs. Ms. Dr.

     	from our organization will serve on the 2017 Board of Examiners.
     	E-mail address

I understand that the nominee or the organization will cover travel and hotel costs associated with participation in Examiner Preparation. I also understand that if my organization is determined to be ineligible to apply for the Baldrige Award in 2017, this examiner nomination will not be considered for the 2017 Board of Examiners.

15. Fee

Indicate your method of payment for the $360 eligibility certification fee.

Check (enclosed) Money order (enclosed) Make payable to the Malcolm Baldrige National Quality Award.
ACH payment Wire transfer		Checking ABA routing number: 075-000-022 Checking account number: 182322730397
Before sending an ACH payment or wire transfer, notify the American Society for Quality (ASQ; [414] 298-8789, ext. 7205, or mbnqa@asq.org). Reference the Baldrige Award with your payment.
Visa MasterCard American Express
Card number	     		Authorized signature
Expiration date	     		Printed name	     
Card billing address	     		Today’s date	     

W-9 Request: If you require an IRS Form W-9 (Request for Taxpayer Identification Number and Certification), contact ASQ at (414) 298-8789, ext. 7205.

16. Self-Certification and Signature

I state and attest the following:

1. I have reviewed the information provided in this eligibility certification package.

2. To the best of my knowledge,

• this package includes no untrue statement of a material fact, and

• no material fact has been omitted.

3. Based on the information herein and the current eligibility requirements for the Malcolm Baldrige National Quality Award, my organization is eligible to apply.

4. I understand that if the information is found not to support eligibility at any time during the 2017 award process, my organization will no longer receive consideration for the award and will receive only a feedback report.

	     	     
Signature of highest-ranking official	Printed name	Date

17. Submission

To be considered for the 2017 award, send your complete eligibility certification package postmarked no later than February 22, 2017, to

Malcolm Baldrige National Quality Award
c/o ASQ—Baldrige Award Administration
600 North Plankinton Avenue
Milwaukee, WI 53203
(414) 298-8789, ext. 7205

Include proof of the mailing date. Send the package via

• a delivery service (e.g., Airborne Express, Federal Express, United Parcel Service, or the United States Postal Service [USPS] Express Mail) that automatically records the mailing date or

• the USPS (other than Express Mail), with a dated receipt from the post office.

1. Eligibility Certification Form*

I have answered all questions completely.

I have included a line-and-box organization chart showing all components of the organization and the name of each unit or division and its leader.

The highest-ranking official has signed the form.

For Organizations Submitting Additional Eligibility Screening Materials (to meet the new alternative eligibility condition no. 7 for question 6k; see the table on page E-4)

I have enclosed a complete Organizational Profile.

I have enclosed data for two results measures for each of the five Criteria results items.

For Subunits Only

I have included a line-and-box organization chart(s) showing the subunit’s relationship to the parent’s highest management level, including all intervening levels.

I have enclosed copies of relevant portions of an official document clearly defining the subunit as a discrete entity.

*Please do not staple the pages of this form.

2. Fee

I have indicated my method of payment for the nonrefundable $360 eligibility certification fee.

If paying by check or money order, I have made it payable to the Malcolm Baldrige National Quality Award and included it in the eligibility certification package.

3. Submission and Examiner Nomination

I am nominating a senior member of my organization to the 2017 Board of Examiners.

I am not nominating a senior member of my organization to the 2017 Board of Examiners.

I am sending the complete eligibility certification package to

Malcolm Baldrige National Quality Award
c/o ASQ—Baldrige Award Administration
600 North Plankinton Avenue
Milwaukee, WI 53203
(414) 298-8789, ext. 7205

I have included proof of the mailing date. (See Application Form and Content instructions at http://www.nist.gov/baldrige/enter/format.cfm/.)

North American Industry Classification System (NAICS) Codes

Please insert NAICS codes most relevant to your organization’s products and/or services in the Eligibility Certification Form. For more information about the NAICS codes, go to http://www.census.gov/eos/www/naics/.

Code Sector

111 Crop Production

112 Animal Production and Aquaculture

113 Forestry and Logging

114 Fishing, Hunting and Trapping

115 Support Activities for Agriculture and Forestry

211 Oil and Gas Extraction

212 Mining (except Oil and Gas)

213 Support Activities for Mining

221 Utilities

236 Construction of Buildings

237 Heavy and Civil Engineering Construction

238 Specialty Trade Contractors

311 Food Manufacturing

312 Beverage and Tobacco Product Manufacturing

313 Textile Mills

314 Textile Product Mills

315 Apparel Manufacturing

316 Leather and Allied Product Manufacturing

321 Wood Product Manufacturing

322 Paper Manufacturing

323 Printing and Related Support Activities

324 Petroleum and Coal Products Manufacturing

325 Chemical Manufacturing

326 Plastics and Rubber Products Manufacturing

327 Nonmetallic Mineral Product Manufacturing

331 Primary Metal Manufacturing

332 Fabricated Metal Product Manufacturing

333 Machinery Manufacturing

3331 Agriculture, Construction, and Mining Machinery Manufacturing

3332 Industrial Machinery Manufacturing

3333 Commercial and Service Industry Machinery Manufacturing

3334 Ventilation, Heating, Air-Conditioning and Commercial Refrigeration Equipment Manufacturing

3335 Metalworking Machinery Manufacturing

3336 Engine, Turbine, and Power Transmission Equipment Manufacturing

3339 Other General Purpose Machinery Manufacturing

334 Computer and Electronic Product Manufacturing

3341 Computer and Peripheral Equipment Manufacturing

3342 Communications Equipment Manufacturing

3344 Semiconductor and Other Electronic Component Manufacturing

335 Electrical Equipment, Appliance and Component Manufacturing

3353 Electrical Equipment Manufacturing

3359 Other Electrical Equipment and Component Manufacturing

336 Transportation Equipment Manufacturing

337 Furniture and Related Product Manufacturing

339 Miscellaneous Manufacturing

423 Merchant Wholesalers, Durable Goods

424 Merchant Wholesalers, Nondurable Goods

425 Wholesale Electronic Markets and Agents and Brokers

441 Motor Vehicle and Parts Dealers

442 Furniture and Home Furnishings Stores

443 Electronics and Appliance Stores

444 Building Material and Garden Equipment and Supplies Dealers

445 Food and Beverage Stores

446 Health and Personal Care Stores

447 Gasoline Stations

448 Clothing and Clothing Accessories Stores

451 Sporting Goods, Hobby, Musical Instrument, and Book Stores

452 General Merchandise Stores

453 Miscellaneous Store Retailers

454 Nonstore Retailers

481 Air Transportation

482 Rail Transportation

483 Water Transportation

484 Truck Transportation

485 Transit and Ground Passenger Transportation

486 Pipeline Transportation

487 Scenic and Sightseeing Transportation

488 Support Activities for Transportation

491 Postal Service

492 Couriers and Messengers

493 Warehousing and Storage

511 Publishing Industries (except Internet)

512 Motion Picture and Sound Recording Industries

515 Broadcasting (except Internet)

517 Telecommunications

519 Other Information Services

521 Monetary Authorities—Central Bank

522 Credit Intermediation and Related Activities

5221 Depository Credit Intermediation

5222 Nondepository Credit Intermediation

5223 Activities Related to Credit Intermediation

523 Securities, Commodity Contracts, and Other Financial Investments and Related Activities

5231 Securities and Commodity Contracts Intermediation and Brokerage

5232 Securities and Commodity Exchanges

5239 Other Financial Investment Activities

524 Insurance Carriers and Related Activities

525 Funds, Trusts, and Other Financial Vehicles

5251 Insurance and Employee Benefit Funds

5259 Other Investment Pools and Funds

531 Real Estate

532 Rental and Leasing Services

533 Lessors of Nonfinancial Intangible Assets (except Copyrighted Works)

541 Professional, Scientific and Technical Services

551 Management of Companies and Enterprises

561 Administrative and Support Services

562 Waste Management and Remediation Services

611 Educational Services

6111 Elementary and Secondary Schools

6112 Junior Colleges

6113 Colleges, Universities, and Professional Schools

6114 Business Schools and Computer and Management Training

6115 Technical and Trade Schools

6116 Other Schools and Instruction

6117 Educational Support Services

621 Ambulatory Health Care Services

6211 Offices of Physicians

6212 Offices of Dentists

6213 Offices of Other Health Practitioners

6214 Outpatient Care Centers

6215 Medical and Diagnostic Laboratories

6216 Home Health Care Services

6219 Other Ambulatory Health Care Services

622 Hospitals

623 Nursing and Residential Care Facilities

624 Social Assistance

711 Performing Arts, Spectator Sports, and Related Industries

712 Museums, Historical Sites, and Similar Institutions

713 Amusement, Gambling, and Recreation Industries

721 Accommodation

722 Food Services and Drinking Places

811 Repair and Maintenance

812 Personal and Laundry Services

813 Religious, Grantmaking, Civic, Professional, and Similar Organizations

814 Private Households

921 Executive, Legislative, and Other General Government Support

922 Justice, Public Order, and Safety Activities

923 Administration of Human Resource Programs

924 Administration of Environmental Quality Programs

925 Administration of Housing Programs, Urban Planning, and Community Development

926 Administration of Economic Programs

927 Space Research and Technology

928 National Security and International Affairs

999 Unclassified Establishments