Before completing the nomination, please review the Guidelines & Instructions.

We recommend that you compile your answers in a separate document and then paste them into the fields on this form. In the event of a submission error, this will preserve your answers so that you may simply re-paste them into each field instead of having to retype them. Please note that all fields are required.


Award Category

Sybil G. Jacobs Award for Outstanding Use of Tobacco Industry Documents
Christine O. Gregoire Youth/Young Adult Award for Outstanding Use of Tobacco Industry Documents


Nominee Information

Nominee's first name:
 

Nominee's last name:
 

Nominee's credentials:
 

Nominee's primary telephone number:
 

Nominee's secondary telephone number (optional):
 

Nominee's email address:
 

Nominee's position title:
 

Nominee's employer:
 

Nominee's responsibilities:
 


Nominator Information

Nominator's first name:
 

Nominator's last name (including credentials):
 

Nominator's relationship to nominee: (including number of years known)
 

Nominator's address line 1:
 

Nominator's address line 2:

Nominator's city:
 

Nominator's state:
  AL Alabama AK Alaska AS American Samoa AZ Arizona AR Arkansas CA California CO Colorado CT Connecticut DE Delaware DC District of Columbia FL Florida GA Georgia GU Guam HI Hawaii ID Idaho IL Illinois IN Indiana IA Iowa KS Kansas KY Kentucky LA Louisiana ME Maine MP Marianas Islands MD Maryland MA Massachusetts MI Michigan MN Minnesota MS Mississippi MO Missouri MT Montana NE Nebraska NV Nevada NH New Hampshire NJ New Jersey NM New Mexico NY New York NC North Carolina ND North Dakota OH Ohio OK Oklahoma OR Oregon PA Pennsylvania PR Puerto Rico RI Rhode Island SC South Carolina SD South Dakota TN Tennessee TX Texas UT Utah VT Vermont VI U.S. Virgin Islands VA Virginia WA Washington WV West Virginia WI Wisconsin WY Wyoming

Nominator's zip code:
 

Nominator's primary telephone number:
 

Nominator's secondary phone number (optional):
 

Nominator's email address:
 

Questions

Please answer each question. Use 250 words or less to answer each question.

Question 1
What is the nominee's involvement in the tobacco control field? How long has he or she been active in this area?
 

Question 2
How has the nominee used the tobacco industry documents in his or her work?
 

Question 3
What makes the nominee's use of tobacco industry documents unique and innovative for policy, advocacy, or research?
 

Question 4
What is the impact of the nominee's work with tobacco industry documents on public health or public policy initiatives? Describe changes that have resulted from his or her work:
 

Question 5
Describe "lessons learned" from the nominee's work that are applicable to other potential uses of documents in research, policy or advocacy:
 

Question 6
For Youth Award Only:
How has the nominee's work raised awareness or demonstrated leadership among the nominee's peer group?
 

 A minimum of two letters of support must be included in the application. In addition, two other supporting documents may be submitted (i.e. research articles, news articles, educational materials, etc). (All documents should be uploaded electronically in Word or pdf format). One of the letters of support must be from someone other than the direct supervisor/boss of the nominee or any employee of the organization/company for which the nominee is a member of the board of directors. Organization letters should be signed by the leader(s) of the organization. Letter writers are encouraged to include relevant quotes, anecdotes, and experiences that help describe the impact of the nominee's use of tobacco documents in research, policy, or advocacy.

You will be directed next to a file upload page. A maximum of 5 documents can be uploaded.
Please note that you must submit at LEAST one document. They may include resumes,
letters of recommendation, curriculum vitae, etc.  The only acceptable formats are
MS Word (.DOC) and Adobe (.PDF). The upload process may take a few minutes; so, please
be patient.
 

   

Any questions or concerns, please email Virginia Lockmuller at: awards@americanlegacy.org or call: 202-454-5555.