2012 Samuel J. Heyman Service to America Medals Nomination Form

Fields required to save an INCOMPLETE nomination are in bold and preceded by a black *
Fields required to submit a COMPLETE nomination are preceded by a red *

*Medal Category:

- Select - Call to Service Career Achievement Citizen Services Homeland Security Justice and Law Enforcement Management Excellence National Security and International Affairs Science and Environment

At the discretion of program administrators, all nominations will be considered for additional categories, if appropriate. If you would like to nominate the same candidate for multiple categories, you must repeat the nomination process for each category. All finalists will be considered for the Federal Employee of the Year award. You cannot specifically nominate someone for this category.

Nominee Information

In this section, please enter the nominee’s employment and contact details.

*Team nomination?

Yes No

Note: if yes, please enter the nominee information for the team leader only.

*Prefix:

(e.g., Mr., Mrs., Ms., Amb., Dr.)

**First Name:

**Last Name:

*Employer:

(agency and office / division)

*Job Title:

*Pay Category:

- Select - General schedule or similar Wage grade Executive (SES or equivalent) Other

*Pay Grade:

* Total Years of
Federal Service:

*Office Mailing Address:

Office Mailing Address Line 2:

*Office City:

*Office State:

*Office Zip Code:

Office Country:

*Office Phone:

(###-###-####, ext. ###)

Home City:

Home State:

Alternate Phone:

(###-###-####)

*Office Email:

Alternate Email:

*Year of Birth:

(YYYY)

Nominator Information

In this section, please enter the nominator’s employment and contact details.

*Prefix:

(e.g., Mr., Mrs., Ms., Amb., Dr.)

**First Name:

**Last Name:

*Job Title:

*Employer:

*Office Mailing Address:

Office Mailing Address Line 2:

*Office City:

*Office State:

*Office Zip Code:

Office Country:

**Phone:

(###-###-#### ext. ###)

**Email:

Alternate Email:

*Relationship:

(Nominator to nominee)

Did you see or hear any of the following Sammies announcements? Check all that apply:

Agency internal announcement
Announcement by an interagency organization:
       
Announcement by a non-government organization:
       
Saw or heard a news article about the Sammies
Radio Public Service Announcement
Television Public Service Announcement
Washington Post Express ad
Partnership for Public Service email
Partnership for Public Service presentation
I attended another Partnership event or program:
       
I previously participated in Sammies as a nominee, nominator or reference
Word of mouth from a friend or colleague
Website listing
Other:
       

Submitter Information (if applicable)

Please complete this section if you are not the official nominator but are entering the nomination on his/her behalf. As the submitter, you will automatically receive program updates that are sent to the nominator. We will also contact you if we have questions regarding the completed nomination.

Prefix:

(e.g., Mr., Mrs., Ms., Amb., Dr.)

First Name:

Last Name:

Job Title:

Employer:

Phone:

(###-###-#### ext. ###)

Email Address:

If you are a submitter, you must include your email to directly receive a confirmation email

References

In this section, please identify and provide contact information for three references, including a current supervisor or higher level official, who can verify the information contained in this nomination. The nominator is automatically considered a reference and should not be repeated below.

Reference #1

*Prefix:

(e.g., Mr., Mrs., Ms., Amb., Dr.)

*First Name:

*Last Name:

*Job Title:

*Employer:

*Phone:

(###-###-#### ext. ###)

*Email:

Reference #2

*Prefix:

(e.g., Mr., Mrs., Ms., Amb., Dr.)

*First Name:

*Last Name:

*Job Title:

*Employer:

*Phone:

(###-###-#### ext. ###)

*Email:

Reference #3

*Prefix:

(e.g., Mr., Mrs., Ms., Amb., Dr.)

*First Name:

*Last Name:

*Job Title:

*Employer:

*Phone:

(###-###-#### ext. ###)

*Email:

Accomplishment Summary

*In one or two sentences, please identify the specific accomplishment(s) for which you are nominating this person or team.

Accomplishment Description

*In 500 words or less:

• Indicate when the accomplishment occurred.
• Explain who the accomplishment benefits and how it benefits them.
• Explain what the nominee did that was innovative (e.g., unique approach to solving a problem or a new model for others to follow).
• Describe why the accomplishment is important to the nation.
• If this is a team nomination, provide the Team Name and Number of Team Members. If there are more than two or three team members, you do not need to identify them at this time.

Additional Information

In 300 words or less, describe any additional attributes or activities that exemplify the nominee's commitment to public service, such as:

• What motivated the nominee to become a public servant or select his or her particular career field.
• The nominee's role as a mentor or workplace leader.
• Other recognition or awards the nominee has received during his or her career.
• Community service or volunteer projects performed by the nominee during the last three years (since January 1, 2009).

If this is a team nomination, you may also name and highlight other prominent members.

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After clicking the Submit or Save Incomplete button, your browser will show a confirmation page that verifies the information was saved. You will also receive a confirmation email at the Nominator and Submitter email addresses entered above. If your browser remains on this nomination form, the nomination was not saved. Please review the form carefully to be sure all required fields have been filled correctly. If you have any questions, please send an email to sammies@ourpublicservice.org or call Shannon Burke-Kranzberg at (202) 464-5382.