Attachment I- Application Form 9600-023

Month Day, Year

ATTACHMENT I

Safer Choice Program Partner of the Year Awards Application Form

OMB Control No. 2070-NEW

Approval expires XX/XX/XX

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2070-NEW). Responses to this collection of information are voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be 15 hours per response, including the time for reviewing instructions, gathering information, posting information to the internet, and reviewing and completing the application. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to the Regulatory Support Division Director, U.S. Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.

2 022 Safer Choice Partner of the Year Awards

Instructions for Application Form

As part of its environmental and public health mission, the Safer Choice program partners with businesses to help consumers and commercial buyers identify products with safer chemical ingredients, without sacrificing quality or performance. Toward this end, the Safer Choice program certifies products containing ingredients that have met the program’s specific and rigorous human health and environmental toxicological criteria. The Safer Choice program allows companies to use its label on certified products that contain the safest possible ingredients and perform, as determined by expert evaluation. The Safer Choice program certification represents the highest level of achievement in formulating products that are safer for people and the environment.

Making the Safer Choice program’s mission known to the widest possible audience is key to fully realizing the program’s goals and potential. The purpose of the Partner of the Year award is to recognize partners and stakeholders who have made exceptional contributions to advancing the Safer Choice program’s mission.

The Awards recognize the leadership contributions of Safer Choice partners and stakeholders who, over the past year, have shown achievement in the design, manufacture, selection, promotion, sale, and use of products with safer chemical ingredients, that further outstanding or innovative source reduction. EPA especially encourages submission of award applications that show how the applicant’s work in the design, manufacture, selection, promotion, sale, and use of those products promotes environmental justice, bolsters resilience to the impacts of climate change, results in cleaner air or water, or improves drinking water quality.

The 2022 Partner of the Year Awards will be the eighth annual event, with recognition for Safer Choice partner and stakeholder organizations from five broad categories: (1) Formulators/Product Manufacturers of both consumer and Institutional/Industrial (I/I) products, (2) Purchasers and Distributors, (3) Retailers, (4) Supporters (e.g., non-governmental organizations, including environmental and health advocates, trade associations, academia, sports teams, and others), and (5) Innovators (e.g., chemical manufacturers, technology developers, and others). Within these categories, Safer Choice may elect to give an additional award in the subcategories of “small business” and “sustained excellence.” Organizations that wish to apply in more than one award category must complete individual application packages.

To be eligible for recognition, candidates should complete this application and have it signed by an appropriate company or organization official (e.g., CEO, vice president for governmental affairs, division head, or other authorized signatory). Candidates who are partners should be in good standing with the Safer Choice program (no outstanding compliance issues) and all candidates will be screened for civil and criminal enforcement history.

EPA reserves the right to request at any time additional documentation to confirm that candidates have achieved the criteria for recognition. If documentation is requested but not received within a reasonable time, EPA may deny or withdraw recognition.

Application Process: The application is available online and may be filled out, scanned and emailed (preferred), or submitted in hard copy by mail. Online applications must be electronically signed and sent to the Safer Choice Partner of the Year Awards lead, Linda Rutsch at rutsch.linda@epa.gov and SaferChoice_Support@abtassoc.com.

If you choose to send a hard copy, the application may be mailed to the following address maintained by our contractor (EPA Contract No. EP-W-08-010):

Safer Choice Partner of the Year Awards

c/o Abt Associates Inc.

Attn: Emily Connor

6130 Executive Boulevard

Rockville, MD 20852

P: 301-347-5197

All applications received will be considered public information, and no materials submitted will be returned. All application materials must be received by [date to be determined].

Confirmation of Receipt: You will receive an email within one week confirming receipt of any materials you submit. It will be sent to the contact provided in the award application. If you do not receive confirmation within one week, please contact Linda Rutsch at rutsch.linda@epa.gov or 202-343-9924.

Questions: Questions about the Safer Choice Partner of the Year Awards should be directed to Linda Rutsch at rutsch.linda@epa.gov or 202-343-9924.

Paperwork Burden Estimate

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2070-NEW). Responses to this collection of information are voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be 15 hours per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to the Regulatory Support Division Director, U.S. Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.

Safer Choice Partner of the Year Awards

SECTION 1a: Enter requested information for the authorized representative.	Organization Name
	Contact Name
	Address
	City, State, Zip
	Phone		Fax
	Email
	Website
SECTION 1b: Under which award category are you applying?1		Formulators/Product Manufacturers – both Consumer and Industrial/Institutional (Complete items 1-5 in Section 2)
		Purchasers and Distributors (Complete items 3-5 in Section 2)
		Retailers (Complete items 3-5 in Section 2)
		Supporters – e.g. non-governmental organizations, including environmental and health advocates, trade associations, academia, sports teams, and others who promote Safer Choice and the development and use of safer product formulations (Complete items 4-5 in Section 2)
		Innovators – e.g., chemical manufacturers, technology developers, and others who create innovative ways to advance the goals of the Safer Choice program (Complete items 4-5 in Section 2)
SECTION 1c: Indicate whether your organization is a small business.2 SECTION 1d: Indicate whether your organization should be considered for “sustained excellence.”3		Yes
		No
		Yes
		No

SECTION 2:

Evaluation criteria:

Please describe your company or organization’s activities and accomplishments in furthering the Safer Choice program’s mission. Your narrative must demonstrate your achievement in the design, manufacture, selection, promotion, sale, and use of products with safer chemical ingredients, that further outstanding or innovative source reduction and:

• Be no more than five pages, but may be accompanied by samples of specific promotions, advertisements, or other activities your organization of no more than an additional ten pages.

• Describe your company or organization’s recent activities and accomplishments in as much detail as possible. Be sure to provide measurable results in your written statement—e.g., number of Safer Choice-certified products sold, people reached, ad impressions run, signs posted, newsletters distributed, etc.

• Cumulative accomplishment statements may be included in the Accomplishments Narrative, but data specific to the past year’s activities must be highlighted (e.g., number of users/subscribers, percentage of products carrying the Safer Choice label compared to the prior year).

• Use the information elements listed in the table below to guide development of your narrative.

Criteria for evaluating applications for this award are listed below.

In your Accomplishments Narrative, address the questions appropriate to your organization type (Applicants must address each of the following items, where applicable):
Formulators/Product Manufacturers0 Complete items 1-5 Maximum score per question: 20 20 30 10 20		1. Participation in the Safer Choice Program Number of Safer Choice- certified products and percentage change over previous year Percentage of product line that is Safer Choice-certified and percentage change over previous year. Percentage of total sales that were Safer Choice-certified and percentage change over previous year. Information on leadership in Safer Choice-certified products, including a brief description of any safer chemistry innovations in the product design (e.g., use of a green-chemistry-award-winning ingredient or chemistry that furthers other environmental goals like energy efficiency). 2. Use of the Safer Choice Label Confirm that the Safer Choice label is used appropriately on products, packaging, website and other materials (N.B., the label must appear with the Safer Choice tag line and web address. Consult the Safer Choice Labeling Guide for guidance on proper label use.) Indicate the percentage of Safer Choice-certified products that carry the Safer Choice label and the location of the label on containers (front, back or cap). Provide information on labeling that goes beyond the basic requirements; location of the label on products or packaging is highly desired, e.g., eye-catching placement on the front of containers. Provide examples or pictures to illustrate Safer Choice label use. 3. Promotion and Use of Safer Choice-certified Products Describe your efforts to promote or use Safer Choice-certified products (e.g., featuring Safer Choice in exhibits at industry tradeshows, presentations and other communications; using Safer Choice-certified products to clean homes, stores and facilities). Indicate if you have led or participated in cooperative promotions of the Safer Choice label, such as in-store or web-based notices or advertising. For each significant promotion or use, include information on the role of participants and the duration, reach, and outcomes; promotion of the label in social media, mass media, e.g., TV commercials, is highly valued or at major sporting or other events with media coverage. Submit examples of social media, print, radio, television, or direct-mail advertising, as appropriate. 4. Communications on Safer Choice to Consumers and End-Users Describe your Safer Choice-themed outreach or promotional activities and messaging (e.g., public relations efforts, social media, special events, press releases) Submit noteworthy examples of outreach and promotional efforts (e.g., innovative use of the Safer Choice label and messaging on your organization’s website; brochures or other media with Safer Choice messages and label; development of technology or a computer application that educates the public on and promotes the use of safer products.) Include information on size of audiences, frequency, and reach, and pictorial examples like website screen shots or ads. 5. Innovations in Safer Chemistry and Other Efforts to Advance Safer Choice, Environmental Protection, and Environmental Justice Describe your efforts/successes in developing safer chemicals for use in Safer Choice-certified products (include number of chemicals listed on the Safer Chemical Ingredients List (SCIL) or, CleanGredients database or used in Safer Choice-certified products). Discuss your leadership of or participation in activities related to new or existing Safer Choice projects (beyond safer product labeling). Provide examples of your organization’s commitment to chemical-risk-reduction activities or other environmental and health protection/stewardship initiatives (e.g., to what extent have you used chemicals listed on SCIL or in CleanGredients in your non-Safer Choice-certified products? What activities illustrate your commitment to sustainable operations?) Explain how your work promotes environmental justice, bolsters resilience to the impacts of climate change, results in cleaner air or water, or improves drinking water quality.
Purchasers and Distributors; Retailers Complete items 3-5 Maximum score per question: 3. 35 4. 35 5. 30
Supporters; Innovators Complete items 4-5 Maximum score per question: Supporters 4. 65 5. 35 Innovators 4. 25 5. 75
SECTION 3: Certification of Application	Please have the appropriate company or organization official (e.g., CEO, vice president for governmental affairs, division head, or other authorized signatory) sign here to verify the accuracy of the application.
		Signature of Authorizing Official	Date
		Printed Name and Title	Date

I hereby affirm that the contents of this application are true and accurate to the best of my knowledge, and that I am a representative of the company or organization named above and am duly authorized to sign on its behalf.

1 If submitting multiple applications, please provide justification for belonging to multiple categories.

2 To qualify as a small business, your business must meet the criteria in the Regulatory Flexibility Act/Small Business Regulatory Enforcement Fairness Act (RFA/SBREFA). For more information, please visit http://www.epa.gov/sbrefa/

3 Those that have been promoting Safer Choice for several years or have previously won the Partner of the Year Awards would be considered eligible candidates.

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EPA Form Number 9600-023

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