Before completing this nomination form, please
read through the entire form.
Note the instructions and follow them carefully.
No nominations will be accepted without the $300.00 fee or after the
November 30, 2011
deadline.
Please type or print:
1. Name of the team you are nominating: ______________________________________________
2. Name of the organization submitting the nomination:
____________________________________
3. Person who can respond to questions about this nomination:
Name (typed or printed): ________________________________ Title:
_____________________
Company: _____________________________ Address: _________________________________
City, State, Zip: _________________________________________________________________
Telephone: ___________________ FAX: ___________________ Email: ____________________
4. Nomination Category: Check the category in which the nomination is submitted. The
category is determined by the principal activity of the organization that employs the
nominees.
_____ a. Education: All educational institutions, including K through 12, two
and four year colleges, universities, and technical institutes. Not-for-profit, government
operated, and proprietary institutions are all eligible.
_____ b. Government: All units of federal, state and regional government. It
does not include for-profit firms devoted to providing services or manufactured goods to
government units.
_____ c. Health Care Organizations: All providers of health care, including, but
not limited to, hospitals, nursing homes, HMOs, and health care practices. Not-for-profit,
government operated, and proprietary organizations are all eligible.
_____ d. Manufacturing Industry: All for-profit manufacturing firms with more
than 500 employees. Subsidiary service firms, wholly owned by manufacturing firms and
offering services to external customers, should be submitted in the service category.
_____ e. Service Industry: All for-profit services with over 500 employees.
Subsidiary manufacturing firms, wholly owned by service firms and offering manufactured
products to external customers, should be submitted in the manufacturing category.
_____ f. Small Business: All for-profit manufacturing and service firms with 500
or fewer employees. In counting the number of employees, include those employed by any
parent company and all divisions and subsidiaries.
*To help us verify the category you have chosen, please describe
briefly the products/services offered by your organization.
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
The sponsors reserve the right to reclassify the nomination if doing
so will place it in competition with a significant
group of similar nominations. Dr. Donald Fisher, (901) 543-3551, can help if you are
uncertain about which category
to check.
5. Total team members:
List the names and job titles of the team members, starting with the team leader. A
team may include members who are not employed by the nominating organization, such as
employees of a supplier or customer. Use an additional sheet of paper, if necessary, to
list them all.
| Name |
Job Title |
|
_______________________________________ |
_______________________________________ |
|
_______________________________________ |
_______________________________________ |
|
_______________________________________ |
_______________________________________ |
|
_______________________________________ |
_______________________________________ |
|
_______________________________________ |
_______________________________________ |
In answering questions 6, 7, 8 and 9, please:
- OBSERVE THE WORD LIMITS
- PROVIDE A WORD COUNT FOLLOWING EACH RESPONSE
These are included in the criteria the judges consider. Additional exhibits, amounting
to as many as six 8 ˝ x 11 pages, may be used to supply supporting statistical evidence
in tabular or graphic form. It is expected that statements made in response to these
questions are verifiable and that nominees will be prepared to provide verification if it
is requested.
6. Brief description: In no more than four hundred words, summarize the quality
improvement for which this team is being nominated.
7. Process (400 Points): In no more than four hundred words, describe the process that
led to the quality improvement. In scoring this section, judges consider the
appropriateness of team composition and its empowerment, the appropriate employment of
quality tools, customer-driven goals, the role of leadership, reproducibility of the
quality improvement process, and commitment to continuous improvement.
8. Measurement (200 Points): In no more than two hundred words, describe the data and
the method of analysis you used to measure the magnitude of improvement, and explain your
choice of data and method. The judges will consider the relevance of the data and the
appropriateness of the method of analysis. They will not expect more complexity than
required for good measurement.
9. Result (400 Points): In no more than four hundred words, describe the improvement,
its impact on the organization, the customers who benefit, and the magnitude of the
benefit.
10. Briefly, is there anything else we should know about this team?
11. Release: Quality Cup nominations provide valuable illustrations of processes for
achieving and measuring quality, continuous improvement, and customer satisfaction. Please
indicate whether you are willing to allow such use of your nomination.
_____ a. Information in the nomination may be used for the purpose of teaching and
research.
_____ b. Information in the nomination may be used for the purpose of teaching and
research, but only after I have had an opportunity to review the use to which it will be
put.
_____ c. Information in the nomination may not be used for teaching or research.
12. Signature of an officer or executive whose span of authority includes the nominee.
Signature: _____________________________________________ Date: _______________
Name (typed or printed): _____________________________________________________
Title: ____________________________________________________________________
Company: ________________________________________________________________
Address: _________________________________________________________________
Telephone number: _________________________ Fax number: _______________________
E-mail address: ______________________________
Mail the signed original, along with three copies, and the $300.00 nomination fee,
payable to MSQPC - The Quality Center.
Dr. Donald C. Fisher
Executive Director/CEO
MSQPC - The Quality Center
22 North Front, Suite 200
Memphis, TN 38103
REV 03/11
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Quality Cup Award |