2019 Nomination Form

Welcome! Thank you for your interest in submitting a nomination for the 2019 Samuel J. Heyman Service to America Medals.

To save an incomplete nomination and return to it later, click the “Save my progress and resume later” checkbox near the top of each page.

If you have any questions, please contact Jim Seymour at [email protected] or (202) 775-9111. Also, be sure to read our guide to writing a winning nomination.

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Nomination and Nominee Information

Nomination Information


Not sure which category to select? Read the category descriptions and criteria for guidance. Please note that all finalists will be considered for the Federal Employee of the Year award. You cannot specifically nominate someone for this category.

If YES, please enter nominee information below for a single team leader. You will have the opportunity to recognize other team leaders/members in the Accomplishment Description.

Nominee Information










Nominees for the Career Achievement category must have 20 or more years of service as of January 1, 2019.


Contact Information






Office Mailing Address






Submitter Information
(i.e., the person completing this form)








Official Nominator Information (Optional)
Please complete this section if you are submitting this nomination on behalf of a senior official. Only the submitter (above), not the official nominator, will automatically receive a confirmation of a completed nomination. We will also contact the submitter if we have questions regarding the completed nomination.







Reference Information
Identify and provide contact information for three references, including a current supervisor or higher level official, who can verify the information contained in this nomination. The nominator is automatically considered a reference and should not be repeated below.

REFERENCE #1









REFERENCE #2









REFERENCE #3








Accomplishment Information

In one or two sentences, please identify the specific accomplishment(s) for which you are nominating this person or team. The primary accomplishment must be related to the nominee’s work as a federal employee (i.e., not community, volunteer or active duty service).

In 800 words or less:
  • Describe the accomplishment and why it is important to the nation. Where possible, include quantifiable outcomes (e.g., dollars saved or number of people helped).
  • Explain who the accomplishment benefits and how it benefits them.
  • Indicate when the accomplishment occurred.
  • Explain what the nominee did that was innovative.
  • If this is a team nomination, provide the team name and number of team members. If there are more than two or three team members, you do not need to identify them at this time.