WWW.READY.GOV/PREPAREDNESS-AWARDS

Application FormFEMA Individual and Community Preparedness Awards

Please read the How to Apply for a FEMA Individual and Community Preparedness Award prior to

starting your application.

Thank you for your commitment to preparedness.

Congratulations on your accomplishments that have led to this application!

I. General Information

Applicant Name:

* Note: If awarded, the name in this field will be used on the award certificate and all public releases. If you areapplying as an organization, it is recommended that you enter the organization’s name here.

Primary Contact Name:

* Note: Please indicate only one contact person.

Contact Title,

if applicable:

Contact Organization,

if applicable:

Address:

Address:

City: State: ZIP:

Contact Email Address:

Phone: Alternative Phone:

WWW.READY.GOV/PREPAREDNESS-AWARDS

Sector: Select only one of the following that best represents the organization associated with the applicant:

¨ Public (local/state government)

¨ Private (for-profit business)

¨ Community-based or Faith-based Organization (non-profit)

¨ Educational Institution (school)

¨ House of Worship (e.g. church, temple, mosque)

¨ Individual

¨ Other (e.g. medical facility, family, national organization) (Please Describe):

Award Category: Descriptions and eligibility requirements can be found in the How to Apply for a FEMA Individual and Community Preparedness Award located at www.ready.gov/preparedness-awards.

Please select no more than two (2) categories from the following:

Outstanding Citizen Corps Council

• The applicant should be registered and approved via the Citizen Corps website:

https://www.citizencorps.fema.gov/cc/secure/index.do

Community Preparedness Champions

• The applicant should be an individual or a group of no more than 15 people.

Awareness to Action

Technological Innovation

Outstanding Achievement in Youth Preparedness

• The achievement should align with the National Strategy for Youth Preparedness Education:

https://www.fema.gov/media-library/assets/documents/96107

John D. Solomon Whole Community Preparedness

• The applicant should represent an organization, program or jurisdiction, rather than a specific individual.

• The applicant should not have any affiliation with any other John D. Solomon award or achievement.

Outstanding Private Sector Initiatives

• The applicant should represent a for-profit small business, as defined by the Small Business

Administration (SBA) (definition provided).

Outstanding Community Emergency Response Team (CERT) Initiatives

• The applicant should be registered and approved via the Citizen Corps website:

https://www.citizencorps.fema.gov/cc/secure/index.do

WWW.READY.GOV/PREPAREDNESS-AWARDS

Outstanding Citizen Corps Partner Program

• The applicant should represent one of the following: Fire Corps, Neighborhood Watch, Medical Reserve

Corps, Volunteers in Police Service, and/or CERT.

Prepareathon in Action

• The Prepareathon (formerly America’s PrepareAthon!) event should have been registered on the website

located here: www.ready.gov/prepare

Which of the following information sources prompted you to apply: ¨ Electronic Newsletter; Please note the publication source:

¨ Email Message

¨ Word of Mouth

¨ Website; Please note the organization:

¨ Social Media

¨ Video

¨ Other (Please Describe):

II. Attachments

Please provide the file name, type and a brief description of the contents for each supporting document (including letter(s)

of support) submitted with your Application. You may include up to three (3) attachments. Please name each of your

attachment files separately with the applicant name and the attachment number to correspond with the list below:

File Name 1:

PDF Word Excel JPEG PNG

Description 1:

File Name 2:

PDF Word Excel JPEG PNG

Description 2:

File Name 3:

PDF Word Excel JPEG PNG

Description 3:

WWW.READY.GOV/PREPAREDNESS-AWARDS

III. Website Links

Please provide the website address and a brief description for each link, if applicable. You may include up to three (3)

website links to any additional supplemental materials (e.g. videos, photos, newsletters).

Website Link 1:

Description 1:

Website Link 2:

Description 2:

Website Link 3:

Description 3:

IV. Description of Achievement

Complete each section below in the Description of Achievement by typing directly into the space provided in this

Application Form. Each response must be less than 250 words.

Problem Statement: Provide a clear and concise description of the problem(s), challenge(s), or issue(s) that the work presented in the application is meant to address.

WWW.READY.GOV/PREPAREDNESS-AWARDS

Resolution: Briefly describe the plan used to address the problem(s), challenge(s) or issue(s) outlined in the problem statement.

Project/Program Description: Summarize the project/program activities and achievements, and how they have helped to resolve the problem(s), challenge(s) or issue(s) outlined in the Problem Statement. Ensure that the audience your activities have served (e.g., stakeholders, students, community leaders, local elected officials) are indicated.

WWW.READY.GOV/PREPAREDNESS-AWARDS

cio-

Results/Impact: Describe the results or impact the activities have had on the community and its population.

Whole Community Inclusivity: Describe what actions or activities you have organized to enhance preparedness among historically underserved populations within your community, to include populations disproportionately affected by disasters. Such actions or activities may include using preparedness information that is accessible to all audiences, including those of varying soeconomic status, diverse cultures, people with disabilities, and those with access and functional needs.

V. Submission

Please ensure that the total email submission size is no more than five megabytes (5 MB).

Save the Application Form per the required naming format indicated in the How to Apply for a FEMA Individual and Community Preparedness Award.

VI. Application Disclaimers

Consent for Use Please note that by applying for the FEMA Individual and Community Preparedness Awards, you consent to allow FEMA

use of the contents of your application on FEMA websites, in blogs, and in other communications. FEMA will contact

you first in the event the Agency wishes to promote, share, or use the contents of your application.

Privacy Your contact information is being collected solely for use of the FEMA Individual and Community Preparedness Awards

application process. Your information will not be shared or used by any external entity beyond those participating in the

application review process including FEMA and partners from the emergency management industry.

Compliance

All applicants shall comply with the General Rules regarding misconduct as noted in the Volunteer Protection Act of 1997

(https://www.gpo.gov/fdsys/pkg/PLAW-105publ19/pdf/PLAW-105publ19.pdf) as well as the Community Emergency

Response Team (CERT) Liability Guide: A Positive Public Image (https://www.fema.gov/media-library-

data/1456408593274-55025c570bf0612ab8940cbbab0e8eae/cert_liability_guide_508_111615.pdf). Any questions

regarding compliance should be addressed by email prior to submitting an application (FEMA-ICP-

Awards@fema.dhs.gov).

Paperwork Burden Disclosure Notice FEMA Individual and Community Preparedness Awards Application Process Public reporting burden for this data collection is estimated to total one hour and forty-five minutes. The burden estimate

includes the time for reviewing application guidance and instructions in the How to Apply for a FEMA Individual and Community Preparedness Award document, searching existing data, sources, gathering and maintaining the data needed,

and completing and submitting your application.

This collection of information and applying to the FEMA Individual and Community Preparedness Awards is voluntary.

Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to:

Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500

C Street, SW., Washington, DC 20472-3100.

NOTE: Do not send your completed application to the Information Collections Management address.

WWW.READY.GOV/PREPAREDNESS-AWARDS