Nomination form

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* 1. Nominee

Name of the organization or individual:

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* 2. Mailing Address:

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* 3. Phone:

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* 4. Fax:

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* 5. Email:

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* 6. Website:

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* 7. Name and title of primary contact:

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* 8. Duration of the Initiative

Date
Date
Description of the initiative in support of agricultural mental health

Note : Each question has a word limit beside it that cannot be exceeded.

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* 9. GENERAL FIT - Provide a basic description of this initiative: How is it linked to agricultural mental health? What is its core purpose, target population, and what primary activities are undertaken to achieve these? (200 words)

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* 10. PRODUCER INVOLVEMENT - To what extent were producers involved in the realization of this initiative? How? Who else was involved and why? (100 words)

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* 11. DEFINED NEED - What need or gap was this initiative intended to address? What motivated you to find a solution? (100 words)

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* 12. DEFINED IMPACT - How have you measured the impact of this initiative? Describe how the target community has been impacted by this initiative. (150 words)

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* 13. WHAT ELSE IS NEEDED - Do you have any suggestions for other types of initiatives, or have you identified other gaps in services/support in the realm of agricultural mental health?(150 words)

What organization or initiative would you like to see receive the donation that accompanies this award?

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* 14. Name:

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* 15. Website:

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* 16. Primary Contact:

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* 17. Email:

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* 18. Telephone:

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* 19. DESCRIPTION: If the potential recipient is distinct from the initiative outlined above, briefly describe how it relates to agricultural mental health, including its core purpose, target population, and primary activities

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* 20. AWARD’S IMPACT: How would the donation that accompanies this award be used to further support agricultural mental health? (100 words)

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