Nomination Form

The period of implementation to be considered is between 1st April 2020 and 31st March 2022.

Please read the rules for Excellence in Governance Awards before proceeding with the nomination.

Section A: Basic Details

Category under which the nomination is being made (Please indicate with a ✓ mark against the required option. For more than 1 nominations, you may in the same form. However, please provide relevant details separately):

☐Innovative Education

☐Healthcare

☐Swachhata

☐Gender & Inclusion

☐Social Welfare

☐Agriculture

☐E-Governance

☐Skill Development

☐MSMEs

☐Start-up & Innovations

☐Sustainability

☐Water

☐Energy

☐Resource Utilisation from Central & State Schemes

☐Jury Special

☐Disaster Management

☐Law & Order

☐Public Amenities

Is this self-nomination?

☐ Yes

☐ No	(If ‘Yes’, you may skip Section B)

Please enter details of the Applicant/Nominee (For Self-nomination):

District:

State:

Name of applicant/ nominee:

Current Designation:

Designation at the time of implementation of initiative:

Mobile number:

Phone:

Email:

Address:

SECTION B: DETAILS OF NOMINATING AUTHORITY

Please enter details of the Nominating Authority (Not applicable in case of self-nomination):

Name of nominating authority:

Name of Organization/ Ministry/ Department/ Administration:

Designation:

Mobile number:

Phone:

Email:

Address:

How did you come to know about this innovative initiative?

How are you connected with this initiative or District Magistrate? Please also highlight if you are a beneficiary or stakeholder of this initiative.

SECTION C: DETAILS OF THE DISTRICT

Please enter details of the District (optional):

Total Area:

Population:

GDP of the district (if available):

Gender Ratio:

Literacy levels:

Infant Mortality Rate (IMR):

Maternal Mortality Rate (MMR):

Unemployment rate:

Total Budget of the district:

Size of the district office (No. of staff members):

Sanctioned positions vs. vacancies:

Additional Information, if any:

SECTION D: DETAILS OF THE INITIATIVE

Please furnish the details about the initiative, under the subheads prescribed below:

Title of the initiative (maximum 20 words)

Department/ Organization/ Administration where the initiative was implemented (maximum 20 words)

Date of commencement of the initiative (dd/month/yyyy) -

What is the current status of the project?

☐On-going

☐Already completed

Executive summary of the initiative (maximum 300 words)

Please provide details of the consultations/community engagement undertaken or any feasibility study conducted before implementation, if any(maximum 200 words)

Please provide details of the problem(s) faced, stakeholders impacted and how the initiative helped in solving that problem and helped the stakeholders. OR What is the nature of impact of this initiative? (maximum 200 words)

Please provide details of the strategies adopted for implementation of this initiative to bring out a positive impact on the society. (maximum 200 words)

Please provide details of publicity or awareness campaigns conducted and information dissemination to stakeholders. (maximum 250 words)

Please elaborate the role and involvement of various stakeholders and people participation in this initiative viz. details on how panchayats, district officers, self-help groups, NGOs and citizens etc. were involved in this initiative. (maximum 250 words)

Please highlight features of the initiative under each of the following dimensions:

Sustainability

Scalability

Cost effectiveness

Replicability

Transparency

Accountability

Write your answer Please provide details of the outcomes or benefits resulting from the intervention(maximum 100 words)

Has the outcome or impact of the initiative been audited or evaluated by any independent agency for the realized benefits vis-à-vis those envisaged?

☐ Yes

☐ No

If yes, please provide brief details thereof (maximum 100 words). Please share any report, if available.

Please provide details of monitoring and feedback mechanism(s) set up for the initiative (maximum 100 words)

SECTION E: ADDITIONAL INFORMATION (to be shared separately)

Please share relevant photographs/videos (compulsory) related to the activity

You may share additional information or supporting documents, or published press releases related to the activity

Any additional comments/declaration/information you wish to provide:

SECTION F: DECLARATION AND SUBMISSION

I, hereby, certify the information and particulars furnished above. All that has been stated above is true and made in good faith. I also certify that no information about the initiative which may be relevant to the assessment process of Awards has been concealed.

The Scheme cited has been operational from not before March 2019.

We/I are not related to the individual concerned by blood or marriage and are not partners in any Company or Financial entity. We/I have not concealed any other information about the innovation or the individual which may be relevant in this case.

References: Would you wish to list any others who may know or be able to vouch for this scheme? Please share their address, designation & organisation and contact number.

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Name: Click or tap here to enter text.

Date:

Phone:

Email:

Signature

Guidelines

Add definition of DM: A District Magistrate (DM), includes Deputy Commissioner or District Collector and other similar nomenclature with functions (except ADM, SDM), is an officer of IAS or an officer of state cadre, who is the head of the district administration, a coordinating officer among various departments and a connecting link between the public and the government so far as he executes the policies, administers the rules and regulations framed by the government from time to time.

You may nominate your entry in one or more of the following award categories.

#	Category	No of Awards
1	Innovative Education	1
2	Healthcare	1
3	Swachhata	1
4	Gender & Inclusion	1
5	Social Welfare	1
6	Agriculture	1
7	E-Governance	1
8	Skill Development	1
9	MSMEs	1
10	Start-up & Innovations	1
11	Sustainability	1
12	Water	1
13	Energy	1
14	Resource Utilisation from Central & State Schemes	1
15	Jury Awards	4
15.1	Disaster Management	1
15.2	Law & Order	1
15.3	Public Amenities	1
15.4	Jury Special	1

Entries for “Jury Special” sub-category is reserved only for nominations by the jury and organising committee.

Eligibility criteria for individual category is mentioned with the categories section.

The application process is FREE. There is no nomination fee for the awards.

District Magistrate or their representatives can nominate projects in as many categories as they want. The same project can be nominated for more than one category (kindly mention the same during the entry)

The entries would be judged based on the questionnaire provided for each of the category. Please try to provide relevant collateral, detailed write-ups and quantitative results / metrics wherever required to strengthen your nomination. Any relevant newspaper articles, published content or Government press releases may please be attached if available

All questions are mandatory. Incomplete responses may be rejected.

The categories of awards shall cover all activities of the respective DMs from the period of 2019 to 2022. In case of ongoing initiatives, the data needs to be provided for completed phases and the results/ impact analysis of the same.

The projects/ initiatives would be judged based on information provided in the nomination forms. However, the jury or the organizing team may also nominate entries.

The entries would be short-listed based on the scoring framework developed by PwC incoherence with the Organising Committee and Jury members.

The Organising Committee may contact the respondents in case of any clarification/validation required. The same would be done through a telephone call / video conferencing.

All decisions on any discrepancy/conflict, selection of winners shall be addressed by the jury members only and its decision will be final and binding.

Please reach out to eigawards@indianexpress.com for any queries.

Kindly send the hard copy of the entry to the below address:

Excellence in Governance Awards

The Indian Express (P) Ltd.

Express Building

B1/B, Sector 10

Noida 201301

Ph. 0120-66515000