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 Sa fe r Choice stakeholders wh o have fu rthered the sa

fe r chemistry goals of the Sa fe r Choice Program through their active and exemplary participation in and promotion of the program

, which f

urthers outstanding and innovative source reduction . Making the Sa fe r Choice Program’s mission known 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 . The Sa fe r Choice Program anticipates that selecting the Partner of th e Ye ar will be a challenging task. Applicants wi th outstanding submissions that do not win the Partner award may receive an honorable mention. The 2016 Partner of

the Year A wards will be the second annual event, wi th recognition f or Sa fe r Choice stakehold er organizations f rom f ive broad categories: (1) Formulators/Product Manuf acturers of

both consumer and Institutional/I ndustrial (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) In novators (e.g., chemical manuf acturers, technology developers, and others) . Within these categories, Sa

fe r Choice may elect to give an additio nal 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 government al 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 availab le 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 Bethes da, MD 20814
- 5341 P: 301
- 634
- 1722 F: 617
- 386
- 8882EPA 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 supple mental 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 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
- 0184 . Approval expires on 01/31/16 . Send comment s 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 Divi sion, 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 con cern 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 stakeholde rs 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 awarene ss 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 sho uld 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 p roducts 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 Manufacturers**  4 Complete items 1

- 5 Maximum score per question : 1. 2 0 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 leade rship in Sa fe r Choice

- labeled products, including a brief

description of

any sa fe r 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 efficie ncy). **2. Use of the Safer Choice**  **Label**  Confirm that the Safer Choice label is used appropriately on products, packaging, web site 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 beyo nd the basic requirements ; location of the label on products or packaging is highly desired, e.g., eye

- catching placement on the f ront 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; advocati ng 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 th e 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 adv ocacy activities and messaging (e.g., public relations efforts, testimony at government hearings, spec ial 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 audience s , frequency, and reach, and pictorial examples like W eb shots or ads. **5. Innovations in Saf er 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 Clean G redients 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 chemical
risk
- reduction activi ties or other environmental and health protection/stewardship initiatives (e.g., to what extent have you used chemicals listed in CleanGredients in your non
- Safer Choice
labeled products? W hat 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 government al 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.