HEA Award - Sanofi U.S.

Due:

DAY

MIN

SEC

* If you are having difficulties accessing the on-line application or have questions, please reach out to HealthEquityAwards@sanofi.com.

Applicant Information

First Name: *

Last Name: *

Phone: *

Email: *

Organization Information

Organization Name: *

Tax ID #: *

Organization Address 1: *

Organization Address 2:

Organization City: *

Organization State: *

Organization Zip: *

Are you a US based non-profit advocacy organization?: *
Note: Only US-based non-profit advocacy organizations are eligible for funding.

Are you submitting on behalf of multiple organizations?: *

If Yes, please list all partners that participated in this solution:

Program Information

Which challenge does your program address?: *

Program Status: *

Name of proposed program to address this challenge: *

Write a short ‘elevator pitch’ to describe the program and how it addresses the challenge: *
Maximum 200 words

Who is target population(s) the program will support and why: *
Share a few insights about the situation and unmet needs of the specific population(s) the program will serve.
Maximum 200 words

The one primary objective of this program is: *
Maximum 75 words

What makes this program innovative and different?: *
Describe novel ideas, partnerships, use of technology, and other factors that bring new approaches to solving the challenge and achieving the objective
Maximum 200 words

How will you implement this program?: *
Tell us about specific activities that will happen to achieve the objective, the implementation timeline, and key milestones for execution.
Maximum 500 words

How will success be measured?: *
Define target results and explain how progress will be tracked including specific metrics and data sources. If this is an existing program, also describe the outcomes to date.
Maximum 300 words

Describe the funding needed for sustainable implementation: *
State how the Health Equity Accelerator Award funding will be utilized, and how any additional funding needed for sustainable operations will be secured.
Maximum 200 words

Additional Information (optional):
Attach any additional information you would like to share.

Health Equity Accelerator Awards Submission

Due:

Applicant Information

Organization Information

Program Information