2021 Nomination Form • Samuel J. Heyman Service to America Medals

Welcome! Thank you for your interest in submitting a nomination for the 2021 Samuel J. Heyman Service to America Medals.

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If you have any questions, please contact Nola Tolsma at [email protected] or (202) 775-9111.

Nomination Details Nomination FAQs Guide to Writing a Winning Nomination

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Welcome to the nomination portal for the 2021 Service to America Medals.

At any time, click 'save my progress' in the upper right hand corner to save your progress and return later.

If you need assistance, please email [email protected]

Nomination Information

Medal Category

Note: For guidance, please read the category descriptions and criteria.
All finalists will be considered for the Federal Employee of the Year award. You cannot specifically nominate someone for this category.

Nominee Information

Note: If you are nominating a team, please enter the information for a single team lead. You will have the opportunity to recognize other team leaders/members below.

Salutation

Other Salutation

First Name

Last Name

Job Title

Federal Department or Agency

Agency Subcomponent/Bureau/Division

Years of Service

Nominees for the Career Achievement category must have 20 or more years of service as of January 1, 2021.

Age

Older than 3535 or younger

Nominees for the Emerging Leaders category must be under 35 as of January 1, 2021.

Nominee Contact Information

Work Email

Alternate Email

Work Phone

Nominee Office Mailing Address

Address Type

United States and TerritoriesInternational (Foreign Bureaus or Embassies should choose this option)

Street Address 1

Street Address 2

City

State

Other State

Zip Code

Country

Street Address 1

Street Address 2

City

Province/State/Territory

Postal Code

Country

Team Information

Is this a team nomination?

YesNo

What is the team's name?

Would you like to list additional team members individually?

Additional Team Member Information

Salutation

Other Salutation

First Name

Last Name

Work Email

Alternate Email

Work Phone

Job Title

Federal Department or Agency

Subcomponent/Office Work Unit

Age

Older than 3535 or younger

Nominees for the Emerging Leaders category must be under 35 as of January 1, 2021.

Address Type

United States and TerritoriesInternational (Foreign Bureaus or Embassies should choose this option)

Street Address 1

Street Address 2

City

State

Other State

Zip Code

Country

Street Address 1

Street Address 2

City

Province/State/Territory

Postal Code

Country

Additional Team Member Information

Salutation

Other Salutation

First Name

Last Name

Job Title

Federal Department or Agency

Subcomponent/Office Work Unit

Age

Older than 3535 or younger

Nominees for the Emerging Leaders category must be under 35 as of January 1, 2021.

Work Email

Alternate Email

Work Phone

Address Type

United States and TerritoriesInternational (Foreign Bureaus or Embassies should choose this option)

Street Address 1

Street Address 2

City

State

Other State

Zip Code

Country

Street Address 1

Street Address 2

City

Province/State/Territory

Postal Code

Country

Please list additional team members here, including their name, title, agency and email.

Nominator and Submitter Information

Are you the nominator or the submitter?

Nominator - I'm writing this nomination myselfSubmitter - I'm submitting this nomination on behalf of the nominator

Hint:

If you know the nominee(s), can describe their work and are submitting this nomination yourself, you're the nominator!

If you are submitting this on behalf of the person who knows the nominee(s) and can describe their work, you're the submitter! (This includes agency awards coordinators, administrative assistants, etc.)

Submitter Information (this is your information, not the nominator's)

Salutation

Other Salutation

First Name

Last Name

Job Title

Employer

Office/Bureau/Division

Work Email

Work Phone

Nominator Information

Salutation

Other Salutation

First Name

Last Name

Job Title

Employer

Office/Bureau/Division

Relationship to nominee (supervisor, colleague, friend, daughter, etc.)

Work Email

Work Phone

Would the Nominator like to receive email updates on the Samuel J. Heyman Service to America Medals program?

Yes, send the Nominator email updates

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

Salutation

Other Salutation

First Name

Last Name

Employer

Job Title

Phone

Reference #2

Salutation

Other Salutation

First Name

Last Name

Employer

Job Title

Phone

Reference #3

Salutation

Other Salutation

First Name

Last Name

Employer

Job Title

Phone

Accomplishment Information

Accomplishment Summary

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).

Accomplishment Description

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 or new.

· For more tips, check out our How to Write a Winning Sammies Nomination guide.

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