Form FY16 National Meda FY16 National Meda FY16 National Medal cover sheet

Entire document included in both clearance packages.
OMB Clearance 3137-0071: Part A Cover sheet
OMB Clearance 3137-0029 Part B-D Nomination form.

2016 Nomination, National Medal for Museum and Library Service
Nomination Form
(To be filled out by the nominated organization.)
A. Cover Sheet
1.

Legal Name of your Organization: 1 _________________________________________________________________
Organizational Unit (if different from Legal Name): ____________________________________________________

2.

Organization Address
Street 1: ____________________________

Street 2: ______________________________________

City: _______________________________

County: _______________________________________

State: ______________________________

Zip+4/Postal Code: ______________________________

3.

Telephone Number: ___________________

4.

Fax Number: ___________________________________

5.

Web Address: http://_____________________________________________________________________________

6.

Name of Organization’s Director/CEO: _______________________________________________________________
Title: __________________________________________________________________________________________
E-mail: ______________________________

7.

Telephone Number: ______________________________

Your Name (the person completing this form): _________________________________________________________
Title: ___________________________________________________________________________________________
E-mail: ______________________________

8.

Type of Organization (check one):

□ Academic Library
□ Aquarium
□ Arboretum/Botanical Garden
□ Art Museum
□ Children’s/Youth Museum
□ Digital Library
□ General Museum 2
□ Historic House/Site
□ History Museum
□ Library Association
□ Library Consortium
□ Museum Library

1

Telephone Number: _______________________________

□ Natural History/Anthropology Museum
□ Nature Center
□ Planetarium
□ Public Library
□ Research Library/Archives
□ School Library, or School District applying on
behalf of a School Library or Libraries
□ Science/Technology Museum
□ Special Library
□ Specialized Museum 3
□ Zoo
□ Other, please specify: ______________________________

If your organization is not an eligible entity on its own, then enter the name and address of the eligible entity under “Legal
Name.” For example, if a library that is part of a parent organization such as a university is applying, it would enter the
university under “Legal Name” and the library under “Organizational Unit.”
2
A museum with collections representing two or more disciplines (e.g., art and history)
3
A museum with collections limited to one narrowly defined discipline (e.g., textiles, stamps, maritime, ethnic group, etc.)

A. Cover Sheet (continued)
9.

Governing Control (check one):

□ State Government
□ County Government
□ City or Township Government
□ Special District Government
□ Regional Organization
□ U.S. Territory or Possession
□ Independent School District
□ Public/State-Controlled Institution of
Higher Education
□ Indian/Native American Tribal
Government (Federally Recognized)
□ Indian/Native American Tribal
Government (Other than Federally
Recognized)
□ Public/Indian Housing Authority

□ Nonprofit with 501(c)3 IRS Status (Other than Institution
of Higher Education)
□ Nonprofit without 501(c)3 IRS Status (Other than Institution
of Higher Education)
□ Private Institution of Higher Education
□ Individual
□ For-Profit Organization (Other than Small Business)
□ Small Business
□ Hispanic Serving Institution
□ Historically Black Colleges and Universities (HBCUs)
□ Tribally Controlled Colleges and Universities (TCCUs)
□ Alaska Native and Native Hawaiian Serving Institutions
□ Nondomestic (non-U.S.) Entity
□ Other, please specify: ______________________________

10. Nominated Organization’s D-U-N-S® Number: 4 ________________________________________________
11. Nominated Organization’s Employer/Taxpayer Number (EIN/TIN): ________________________________
12. Congressional District of Nominated Organization: 5 ____________________________________________
13. Organization’s Annual Operating Budget: ____________________________________________________
14.
A.

Fiscal Year

B.

List Total Revenue/
Support Income 6

C.

List Total Expenses/
Outlays 7

Difference between B. Total
Revenue and
C. Total Expenses

15. If your organization had a deficit greater than 10% of your annual operating budget for any of the fiscal years listed
above, please explain the circumstances of this deficit. [Text box]
16. Has your organization had an A-133 audit in the past three years? Yes; No
17. If no, has your organization had a financial statement audit in the past three years? Yes; No
18. Were there any material weaknesses identified in your organization’s prior year’s audit report? Yes; No; Not
applicable * A material weakness is a deficiency, or combination of deficiencies, in internal control, such that there is
a reasonable possibility that a material misstatement of the entity’s financial statements will not be prevented, or
detected and corrected on a timely basis.
4

Verify that your organization has a D-U-N-S® Number or take steps to obtain one. Your organization can receive a D-U-N-S®
Number at no cost by calling the dedicated toll-free D-U-N-S® Number request line at 1-866-705-5711 or by visiting
www.dnb.com/us.
5
Congressional Districts can be found by inserting the zip code of the institution at the following site:
http://www.house.gov/representatives/find.
6
For nonprofit tax filers Total Revenue can be found on line 12 of the IRS Form 990.
7
For nonprofit tax filers Total Expenses can be found on line 18 of the IRS Form 990.

19. If yes, please explain. [Text box]
20. Number of full-time paid organization staff: _________

Number of part-time paid organization staff: __________

Number of full-time unpaid organization staff

Number of part-time unpaid organization staff

(including volunteers): ___________________________

(including volunteers): ____________________________

21. Total number of days the organization was open to the public for the past 12-month period prior to application: ____
22. Name of Nominating Individual: _____________________________________________________________________
Title: _________________________________________

Relationship to Organization: _______________________

E-mail: _______________________________________

Telephone Number: _______________________________

2016 Nomination, National Medal for Museum and Library Service
(To be submitted by the nominated organization.)
In addition to the Cover Sheet (Section A), your submission must include the following parts (Sections BD below). Do not include additional cover letters, binders, folders, or attachments.
B. Executive Summary and Mission Statement (not to exceed one single-spaced page; no less than 12point font)
• Summarize why you believe your organization deserves to win the National Medal for Museum
and Library Service.
• Provide your organization’s mission statement or statement of purpose as well as a brief
institutional history.
C. Narrative 8 (not to exceed four single-spaced pages; no less than 12-point font)
The National Medals are designed to recognize outstanding libraries and museums that have
made significant contributions in service to their communities. Address questions 1-4
thoroughly and succinctly. The jurors considering the pool of potential medal recipients will
focus carefully on your answers to these questions.
1. Describe the community 9 and the particular community needs addressed.
• Quantify and describe the population groups/communities your organization is reaching
through its programs, services, and/or partnerships.
• What particular community needs do you address? How did you identify these
particular needs?
2. Describe the programming your organization has developed for these particular community
needs. (see section C.1.)
• Provide examples of the programs, services, and/or partnerships you have developed
for these population groups/communities.
• How do you involve your community in the development of your programs?
• How have these partnerships increased your ability to reach out to the targeted
population groups and communities you serve?
• Describe how you serve community members with special needs.
3. Describe what impact your organization’s programs and services have had on the identified
community needs.
• Do you conduct a formal evaluation of your programs? If so, what have you learned
about meeting the needs of your audiences?
• How have you used this information to plan future programs and services?
4. Describe your organization’s financial situation.
8

For organizations applying in the Digital Library category, please address:
•
services to your community including services to other organizations and services to end users;
•
access to resources;
•
sustainability and preservation plans for the digital library;
•
accessibility for people with disabilities (e.g., compliance with the Americans with Disabilities Act).
9
Academic and research libraries may interpret “community” as your campus community and/or local community.

•
•

List your organization’s three primary sources of revenue. Do you have a sustainable
funding model that will enable growth?
Describe any private or non-profit groups that support your mission and activities and
the extent of their support.

D. Letters of Support (required - three maximum, submitted with the Nomination Form)
• These letters should come from community members who have direct knowledge of your
organization’s community service. We recommend that the letters come from different
segments of the broader community served by your organization and from individuals who
have either witnessed or experienced first-hand a particular program or service.
• Nomination letters from members of Congress are welcome and will not count against the
three-letter maximum.
• Address letters to the Director of the Institute of Museum and Library Services and include
them with this Nomination Form.

2016 Nomination, National Medal for Museum and Library Service
Supplementary Information [to be posted on IMLS’s website]
Download FY 2016 Nomination Form (Fill-in PDF, 174KB)
Visit the National Medals page in our National Initiatives section to learn more about the annual
celebration of the National Medal recipients.
Deadline:
Program Contact for Museums:

October 1, 2015
Mark Feitl, Museum Program Specialist
202-653-4635
mfeitl@imls.gov

Program Contact for Libraries:

Katie Murray, Staff Assistant
202-653-4644
kmurray@imls.gov

Program Overview:
The National Medal honors outstanding libraries and museums that have made significant and
exceptional contributions in service to their communities. Selected institutions demonstrate
extraordinary approaches to serving their constituents; they exceed expected levels of community
outreach. These organizations have established themselves as community anchor institutions. Recipient
institutions are honored at an awards ceremony that is held in Washington, DC.
Nominations should describe the:
• population served and community needs;
• institution’s programs, services, and partnerships;
• impact and evaluation of programs; and
• financial sustainability.
How are the recipients of the National Medal selected?
The Director of the Institute of Museum and Library Services, with the advice of the Museum and Library
Services Board, selects the recipients of the National Medals. In addition to the Medal, IMLS may grant
a monetary award.
When are the recipients of the National Medal announced?
The recipients of the National Medals are usually announced in the spring on the IMLS website and
through a press release.
Who is eligible for a National Medal nomination?
For museums:
•

In general: Aquariums, Arboretums/Botanical Gardens, Art Museums,
Children’s/Youth Museums, General Museums, Historic Houses/Sites, History
Museums, Natural History/Anthropology Museums, Nature Centers, Planetariums,
Science/Technology Centers, Specialized Museums, and Zoos may be nominated for

•

•

the National Medal for Museum Service if they: are either a unit of State or local
government or a private nonprofit organization that has tax-exempt status under
the Internal Revenue Code;
are located in one of the 50 States of the United States of America, the District of
Columbia, the Commonwealth of Puerto Rico, the U.S. Virgin Islands, Guam,
American Samoa, the Commonwealth of the Northern Mariana Islands, the Republic
of the Marshall Islands, the Federated States of Micronesia, or the Republic of
Palau; and
qualify as:
o a museum that, using a professional staff, is organized on a permanent basis
for essentially educational or aesthetic purposes; owns or uses tangible
objects, either animate or inanimate; cares for these objects; and exhibits
these objects to the general public on a regular basis through facilities that
it owns or operates.

A public or private nonprofit agency which is responsible for the operation of a museum may
apply on behalf of the museum.
For libraries:
•

•

In general: Academic Libraries, Digital Libraries, Library Associations, Library
Consortia, Public Libraries, Research Libraries/Archives that make information
available to the public and that are not an integral part of an institution of higher
learning, Public School Libraries, and Private or Special Libraries that are considered
libraries as determined by the State in which they are located, may be nominated
for the National Medal for Library Service. They should also be: either a unit of
State or local government or be a private nonprofit organization that has taxexempt status under the Internal Revenue Code; and
located in one of the 50 States of the United States of America, the District of
Columbia, the Commonwealth of Puerto Rico, the U.S. Virgin Islands, Guam,
American Samoa, the Commonwealth of the Northern Mariana Islands, the Republic
of the Marshall Islands, the Federated States of Micronesia, or the Republic of
Palau.

Previous library or museum medal recipients may reapply after ten years.
Who may nominate a library or museum for the National Medal?
Anyone, including the institution’s employees, board members, members of its community, and elected
officials, may nominate a museum or library for this honor.
What steps should nominators take?
• If an institution self-nominates, it simply needs to submit the nomination materials to IMLS by
the deadline.
• If someone outside of the institution wants to make a nomination, they should notify the
museum or library directly and ask them to complete and submit the nomination form in
advance of the deadline.

What information is necessary in order for an institution to be considered for the National Medal and
who is responsible for providing it?
Your institution, not the individual who nominates it, must complete the Nomination Form and include
the following four parts:
A. Cover Sheet
B. Executive Summary & Mission Statement
C. Narrative (four questions)
D. Letters of Support
Do not include additional cover letters, binders, folders, or attachments. For detailed information on
answering parts B-D, refer to the Nomination Form.
What is the deadline for submitting the Nomination Form?
The Nomination Form and letters of support should be sent by October 1, 2015, to this email address:
nationalmedals@imls.gov
Alternatively, nominations may be mailed and postmarked by October 1, 2015, to this address:
The National Medal for Museum and Library Service
Office of the Director
Institute of Museum and Library Services
1800 M St. NW, 9th Floor
Washington, DC 20036-5802