EPA Form 9600-04 Page 1 of 6

Safer Choice 

Partner of the Year Awards 2016

Instructions for Application Form

EPA developed The Partner of the Year Awards to recognize Safer Choice stakeholders who have 

furthered the safer chemistry goals of the Safer Choice Program through their active and 

exemplary participation in and promotion of the program, which furthers outstanding and 

innovative source reduction. Making the Safer Choice Program’s mission known to the widest 

possible audience, through its safer product label and in other forms of communication, is critical 

to fully realizing the program’s goals of protecting human health and the environment, promoting 

a sustainable economy, and creating green jobs. The Safer Choice Program anticipates that 

selecting the Partner of the Year will be a challenging task. Applicants with outstanding 

submissions that do not win the Partner award may receive an honorable mention.

The 2016 Partner of the Year Awards will be the second annual event, with recognition for Safer 

Choice 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 should be in good standing

with the Safer Choice Program (no outstanding compliance issues) and will be screened for 

civil/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 or fax. Online applications must be 

electronically signed and sent to 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: Klara Zimmerman

4550 Montgomery Avenue, Suite 800 North

Bethesda, MD 20814-5341

P: 301-634-1722

F: 617-386-8882
EPA Form 9600-04 Page 2 of 6

Supplemental documents such as photos, pamphlets, copies of advertisements, videos, audio 

files, etc. may be sent with your application (each file must be less than 12MB and total 

submission should not exceed 15 pages). If necessary, you can mail hard copies of 

supplemental material to the contractor address specified above.

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 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 the Safer Choice Partner Awards lead, 

Chen Wen, at wen.chen@epa.gov or 202-564-8849.

Notification: You may be notified as soon as [date to be determined] of the status of your 

application. 

Questions: Questions about eligibility, nomination procedures, or the Safer Choice Program

should be directed to Chen Wen at wen.chen@epa.gov or 202-564-8849.

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 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 OMB control number for this collection is 

2070-0184. Approval expires on 01/31/16.

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 Strategies 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.
EPA Form 9600-04 Page 3 of 6

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 3-5 in Section 2)

Innovators – e.g., chemical manufacturers, technology developers, 

and others who create innovative ways to advance the goals of 

the Safer Choice (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

 

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.
EPA Form 9600-04 Page 4 of 6

SECTION 2:

As part of its environmental mission, the Safer Choice Program partners with businesses and 

others to reduce health and environmental risks by advancing the manufacture and use of safer 

products and technologies. Toward this end, the Safer Choice Program increases awareness of 

the toxicological properties of chemicals through the replacement of chemicals of potential 

concern with safer alternatives. The Safer Choice Program allows the use of its label on products 

that perform well and contain the safest possible ingredients, as determined by expert evaluation 

of the best available science. The Safer Choice Program recognition represents the highest level of 

achievement in formulating products that are safer for families 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 stakeholders who have made exceptional contributions to advancing the Safer Choice 

Program’s mission.

Evaluation criteria:

Criteria for evaluating applications for this award are listed below. Partner of the Year Awards are 

based on activities that increase awareness of the Safer Choice Program, Safer Choice-labeled 

products, and the program’s mission to help safeguard human and environmental health through 

safer chemistry. While general education on the importance of safer chemicals is valued, your 

application should focus on your specific activities and accomplishments to promote the use of 

Safer Choice-labeled products and your actions to advance the program.

Please describe your company or organization’s activities and accomplishments in furthering the 

Safer Choice Program’s mission. Your narrative should:

 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 

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-labeled 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. 

In addition, each applicant will be screened for their history of civil or criminal enforcement 

actions. Results of this screening will be factored into the winner selection process.
EPA Form 9600-04 Page 5 of 6

In your Accomplishments Narrative, address the questions appropriate to your organization 

type:

Formulators/Product 

Manufacturers4

Complete items 1-5

Maximum score per 

question:

1. 20

2. 30

3. 30

4. 10

5. 10

1. Participation in the Safer Choice Program (Applicants must address 

each of the following items.)

 Number of Safer Choice-labeled products and percentage change 

over previous year

 Percentage of product line that is Safer Choice-labeled and 

percentage change over previous year.

 Percentage of total sales that were Safer Choice-labeled and 

percentage change over previous year.

 Information on leadership in Safer Choice-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 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-recognized 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-labeled Products 

 Describe your efforts to promote or use Safer Choice-labeled 

products (e.g., featuring Safer Choice in exhibits at industry 

tradeshows, presentations and other communications; using Safer 

Choice-labeled products to clean homes, stores and facilities; 

advocating for use of labeled products)

 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 mass media, e.g., TV commercials, is highly 

valued or at major sporting or other events with media coverage.

 Submit examples of 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 advocacy activities 

and messaging (e.g., public relations efforts, testimony at 

government hearings, special events, press releases)

 Submit noteworthy examples of outreach and advocacy efforts

(e.g., innovative use of the Safer Choice label and messaging on 

Purchasers and 

Distributors; 

Retailers

Complete items 3-5

Maximum score per 

question:

 3. 40

 4. 40

 5. 20

 

Supporters; 

Innovators

Complete items 4-5

Maximum score per 

question:

 Supporters

 4. 75

 5. 25

 

 Innovators

 4. 25

 5. 75

 

4 All current Safer Choice 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 Safer Choice Partnership Agreement. 
EPA Form 9600-04 Page 6 of 6

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 Web shots or ads.

5. Innovations in Safer Chemistry and Other Efforts to Advance Safer 

Choice and Environmental Protection 

 Describe your efforts/successes in developing safer chemicals for 

use in Safer Choice-labeled products (include number of chemicals 

in CleanGredients database or used in Safer Choice-labeled 

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 chemicalrisk-reduction activities or other environmental and health 

protection/stewardship initiatives (e.g., to what extent have you 

used chemicals listed in CleanGredients in your non-Safer Choicelabeled products? What activities illustrate your commitment to 

sustainable operations?)

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.