### EPA ICR No. 2450.01; OMB Control No. 2070 **- NEW** 

**ATTACHMENT B Design for the Environment**  **Safer Product Labeling Program**

**Partner of the Year Application Form**EPA Form TBD Page 1 of 6 

# Design for the Environment **(DfE) Safer Product Labeling Program**  **Partner of the Year Awards**  Instructions for Application Form EPA developed The Partner of the Year Awards to recognize Df E stakeholders wh o have fu rthered the sa

fe r chemistry goals of the Df E Sa fe r Product Labeling Program through their active and exemplary participation in and promotion of the program. Making Df E’s mission kno wn to the widest possible audience, through its sa fe r product label and in other f orms of communication, is critical to f ully realizing the program’s goals of protecting human health and the environment, promoting a sustainable economy, and creating green jobs, especially in the sma ll business sector. Df E anticipates that selecting the Partner of the Yea r wi ll be a challenging task. Applicants with outstanding applications that do not win the Partner award may receive an honorable mention. The Partner of

the Year Awards wi ll be an annual event, with recognition f or Df E stakeholder organizations f

rom f ive broad categories: (1) Formulators/Product Manuf acturers (of

both consumer and Institutional/ In dustrial (I/ I) products), (2) Purchasers and Distributo rs, (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 manuf acturers, technology developers, and others) . Within these categories, Df E ma y 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 or vice president for government relations ). 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 (e.g., X days) , EPA may deny or withdraw recognition. Application Process : The application is available online and may be filled out and submitted in hard copy by mail , faxed, or scanned and emailed to DfE Partner

@epa.gov. All applications received will be considered public information and no materials submitted will be returned. If you choose to send the application electronically, the application and signed signature page must be scanned and sent to DfE Partner @epa.gov . To be eligible for the awards, which may be announced as soon as fall 2012 , candidates would need to submit their application by summer 2012 [date to be determined] . Supplemental documents such as photos, pamphlets, copies of advertisements, videos, audio files, etc. may be sent with your application as PDF files (each file must be less than 12MB). If necessary, you can mail hard copies of supplemental material to the following address maintained by our contractor (EPA Contract No. XXXXXXXXX) : Design for the Environment Safer Product Labe ling Program Partner of the Year Awards c/o Abt Associates Inc. Attn: Aviva Loew 4550 Montgomery Avenue, Suite 800 NorthEPA Form TBD Page 2 of 6

Bethesda, MD 20814

- 5341 P: 301
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- 8090 Conf irmation of

Receipt: You will receive an email within one week confirming any materials you submit. It will be sent to the Primary Communications contact in the award application. If you do not receive confirmation within one week, please contact the DfE Partner Awards lead, Bridget Williams, at williams.bridget@epa.gov or 202

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- 8558. Notif ication: You may be notified as soon as early fall 2012 of the status of your application . Questions: Questions about eligibility, nomination procedures, or Design for the Environment should be directed to Bridget Williams of EPA’s Design for the Environment Program at williams.bridget@epa.gov or 202

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- 8558. **Paperwork Burden Estimate** The public reporting and recordkeeping burden for this collection of information is estimated to average 15 hours per response, including the time for reviewing instructions, gathering information, and reviewing and completing the application. An agency m ay 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 OMB control number for this collection is 2070
- xxxx . Approval expires on DATE . 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, including through the use of automated collection techniques to the Director, Collection Str ategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. **Do not send the completed application to**  **this address. OMB Control No.**  **2070 -** **NEW Approval expires XX/XX/XX** 

EPA Form TBD Page 3 of 6 Design for Environment

**SECTION 1a: Enter requested**  **information for the authorized**  **representative Organization Name**  **Contact Name Address**  **City, State, Zip Phone**  **Fax Email**  **Website SECTION 1b:**  **Indicate your type of organization**  **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 DfE and the development and use of safer**  **product formulations (Complete items 3**  **- 5 in Section 2)**  **Innovators –**  **e.g., chemical manufacturers, technology developers, and others who create innovative ways to advance the goals of**  **the DfE**  **Safer Product Labeling Program**  **(Complete items 4 -**  **5 in Section 2) SECTION 1c:**  **Indicate whether your organization**  **is a small business. To**  **qualify as a small business, your**  **business must meet the criteria in the**  **Regulatory Flex ibility**  **Act / Small Business Regulatory**  **Enforcement Fairness Act (RFA/SBREFA)**  **1 Yes**  **No**

**1 For more information, please visit the**  **RFA/SBREFA website at http://www.epa.gov/sbrefa/ OMB Control No.**  **2070 -** **NEW Approval expires XX/XX/XX** 

EPA Form TBD Page 4 of 6 **SECTION 2:** As part of its environmental mission, the DfE Safer Product Labeling Program partners with businesses and others to reduce health and environmental risks by advancing the manufacture and use of s afer products and technologies. Toward this end, DfE increases awareness of the toxicological properties of chemicals through the replacement of chemicals of potential concern with safer alternatives. DfE allows the use of its logo on products that perf orm well and contain the safest possible ingredients, as determined by expert evaluation of the best available science. DfE recognition represents the highest level of achievement in formulating products that are safer for families and the environment. Making DfE’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 stakeholders who have made exceptional contributions to advancing DfE’s mi ssion. **Evaluation criteria:** Criteria for evaluating applications for this award are listed below. In addition, each applicant will be screened to determine their history of civil or criminal EPA enforcement actions. Results of this screening will be factored into the winner selection process. Please describe your company ’s or organization ’s activities and accomplishments in furthering DfE’s mission. Your narrative should:  Be no more than **three pages** , but may be accompanied by samples of specific pro motions, advertisements, or other activities your organization.  Describe your company’s or organization ’s recent activities and accomplishments in as much detail as possible.  Cumulative accomplishment statements may be included in the Accomplishments Narrative, but data specific to the past year’s activities must be highlighted. When discussing cumulative accomplishments, ensure that you include a time frame (e.g., reduced the use of chemicals of concern by 100,000 pounds in 2011, and more than 3,000,000 p ounds since 2003).  Use the information elements in the listed in the table below to guide development of your narrative. **Tips for Success:** There are a few steps you can take to ensure a successful application.

 Partner of the Year Awards are based on activities that increase awareness of the DfE Safer Product Labeling Program, DfE

- labeled products , and the program’s mission to help safeguard human and environment health through safer chemistry . While general education on the importance of safer chemic als is valued, your application should focus on your specific activities and accomplishments to promote the use of DfE

- labeled products and your actions to advance the program.  Be sure to provide measurable results in your written statement

—e.g., number o f DfE

- labeled products sold, people reached, advertisements run, signs posted, newsletters distributed, etc.**OMB Control No. 2070**  **- NEW**  **Approval expires XX/XX/XX**

EPA Form TBD Page 5 of 6 **In your Accomplishments Narrative, address the questions appropriate to your organization type:**  Formulators/Product Manufacturers 1 Complete items 1

- 5 **1. Participation in the DfE Safer Product Labeling**  **Program** (Applicants must address each of the following items.)  Number of DfE

- labeled products and percentage change over previous year.  Percentage of product line that is DfE

- labeled and percentage change over previous year.  Percentage of total sales that were DfE

- labeled and percentage change over previous year.  Information on leadership in DfE

- labeled 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 ene rgy efficiency). **2. Use of the DfE Label**  Confirm that the DfE logo is used appropriately on products, packaging, web site and other materials (N.B., the logo must appear with the DfE tag line and web address. Consult the DfE Welcome Handbook for guidance on proper logo use.)  Indicate the percentage of DfE

- recognized products that carry the DfE logo and the location of the logo on containers (front, back or cap).  Provide information on labeling that goes beyond the basic requirements, for example, unique or prominent use of the DfE logo on products or packaging.  Provide examples or pictures to illustrate DfE logo use. **3. Promotion and Use of DfE -**  **labeled Products**  Describe your efforts to promote or use DfE

- labeled products; examples include: featuring D fE in exhibits at industry tradeshows, presentations and other communications; using DfE

- labeled products to clean homes, stores and facilities; and, advocating for use of labeled products.  Indicate if you have led or participated in cooperative promotions of the DfE 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.  Submit examples of print, radio, television, o r direct

- mail advertising, as appropriate. **4. Communications on DfE to Consumers and End -**  **Users**  Describe your DfE

- themed outreach or advocacy activities and messaging; for example, public relations efforts, special events, press releases, etc.  Submit good examples of outreach and advocacy efforts; for Purchasers and Distributors; Retailers Complete items 3

- 5

Supporters ; Innovators Complete items 4

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1 All current DfE Partners may apply. Please note that to be eligible for the Partner of the Year award, partners must be in compliance with all applicable requirements in the DfE Partnership Agreement.**OMB Control No. 2070**  **- NEW**  **Approval expires XX/XX/XX**

EPA Form TBD Page 6 of 6 example, brochures with DfE messages and logo; incorporation of DfE logo and messaging on company website; development of technology or computer application that educates the public on and promotes the use of safer products or environmental messaging in general.  Include information on audience, frequency, and reach, and pictorial examples like W eb shots or ads. **5. Innovations in Safer Chemistry and Other Efforts to Advance DfE and Environmental Protection**   Describe your efforts/successes in developing safer chemicals for use in DfE

- labeled products (include number of chemicals in Cleangredients database or used in DfE

- labeled products).  Discuss your leadership of or participation in activities related to n ew or existing DfE 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.

**SECTION 3: Certification of**  **Application Please have the appropriate company**  **or organization official (e.g., CEO, vice**  **president for government**  **affairs, division head, or other authorized signatory) sign here to verify the accuracy of the application.** 

**Signature of Authorizing Entity 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.