2010 Aesculapius Award Entry Form
(Please complete and return this form with your entry!)
Please use a separate form for each entry. This form may be duplicated. Please type or print.
WWW site address, or title of PSA entry: Producer (to appear on award): |
| Contact Name: | _________________________________________________________________________________ |
| Title: | _________________________________________________________________________________ |
| Company Name: | _________________________________________________________________________________ |
| Address: | _________________________________________________________________________________ |
| City: ______________________________________ | State: ____________________________________ |
| Zip Code: __________________________________ | Phone: ___________________________________ |
| Fax: ______________________________________ | Email: ____________________________________ |
| [ ] WWW site | [ ] TV PSA (VHS or DVD) | [ ] Radio PSA (cassette or CD) |
| WWW site: Approximate number of pages___________ | Length of PSA (seconds) ______________ |
Category of organization primarily responsible for WWW site/PSA (check one)
| [ ] Community group (non-profit) | [ ] Hospital or medical institution | |
| [ ] Corporation (commercial company) | [ ] Media (agency, PR firm, etc.) | |
| [ ] Educational institution | [ ] Production company | |
| [ ] Educational organization or foundation (non-profit) | [ ] Trade or professional association | |
| [ ] Government agency | [ ] Other, specify______________________ |
Description: Please attach 1-page description of the WWW site/PSA to include the following:
• Objective of the WWW site or PSA, including target audience(s); steps in message development
• Names, title and organization of all those responsible for the creation and production of the WWW site orPSA
• Video, audio and/or graphic production facilities used. Explain which production stages were done in house; if from an outsource, name contractor.
• For WWW sites, number of hits in 2009 and/or 2010, for PSAs, number of
TV/radio station airings
• For PSAs, TV/radio stations, dates and approximate time of at least five
airings in 2009 and/or 2010
• Budget; for in house productions, please estimate what it would have cost to produce the WWW/PSA outside
• Describe how the impact of the WWW site or PSA was evaluated and the results of the evaluation.
Entry fee: $100 per entry: Please make checks payable to the "Health Improvement Institute."
Entry Deadline: Entries and accompanying materials are due by September
10, 2010.
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Email:
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