NETWORK ORGANIZATION APPLICATION FORM

Network Organizations are committed to supporting the priority areas of the Action Collaborative on Decarbonizing the U.S. Health Sector (Climate Collaborative) and working together to galvanize a movement to address climate change and protect human health, well-being, and equity.

Criteria for Becoming a Network Organization

Participation is restricted to organizations (legal entities) only. Individuals or groups of individuals are not eligible to become a Network Organization. Note: entities located outside of the U.S. are eligible to apply to become a Network Organization.
Participation is restricted solely to the Climate Collaborative’s Network Organizations and does not include membership in the Climate Collaborative itself, its steering committee, or any of its working groups.
Participation is subject to approval by the National Academy of Medicine of a Commitment Statement submitted in accordance with the criteria described below.

Criteria for Commitment Statements:

Statements should be 500 words or less. If applicable, you may include a link to a longer statement on your website.
Statements should describe organizational (rather than personal) commitments.
The commitment statement must be submitted on the entity's official letterhead.
The commitment statement must begin with a paragraph that clearly describes the mission and purpose of the entity, including a description of any services it provides and/or the products it produces.
The commitment statement must include a paragraph that specifically relates work the entity has underway within one or more of the four priority areas of the Climate Collaborative:
- Health Care Delivery - scaling energy efficient, sustainable, and equitable health care operations and practices, including reducing unnecessary and carbon-intensive health care services
- Health Care Supply Chain and Infrastructure - reducing the climate footprint of the health care supply chain and strengthening its resilience by sharing best practices and advancing innovation in product manufacturing, packaging, and distribution
- Health Professional Education and Communication - empowering health workers and learners to better advocate for decarbonizing health care through education and communication that emphasize the health and equity benefits of climate actions
- Policy, Financing, and Metrics - identifying policies, regulations, metrics, financing, and payment structures to support health sector decarbonization and resilience
The commitment statement may not include any promotional or marketing language about products, services, or material that the entity may develop, support, produce, or distribute.
The commitment statement may reference the entity's participation as a Network Organization within the National Academy of Medicine's Climate Collaborative. The commitment statement may not refer to the entity as a member of the Climate Collaborative, its steering committee, or one of its working groups; as a partner of the National Academy of Medicine; or otherwise state or imply adoption or endorsement by the National Academy of Medicine of the entity or its products or services.
The National Academy of Medicine has sole discretion to determine if these criteria have been met, including a determination of what is promotional or marketing material.

Please direct all questions or comments to ClimateandHealth@nas.edu.

1. Name of organization: *This question is required.

2. Has your organization been incorporated for longer than one year? *This question is required.

3. How would you best categorize your organization? (Please select more than one option if appropriate.) *This question is required.

4. Describe, in 50 words or less, what your organization does. *This question is required.

5. Which one (or more) of the Climate Collaborative's four priority areas is your organization working in? Please refer to the submission guidelines above additional details. *This question is required.

Health care delivery
Health care supply chain and infrastructure
Health professional education and communication
Policy, financing, and metrics

6. Please provide any relevant links to websites or webpages relevant to your organization's work on climate change. Include links to specific webpages only - links to general organizational webpages will be discarded. *This question is required.

7. Upload any files relevant to your organization's work on climate mitigation and resilience. Word documents and PDFs will be accepted.

File: {{filename}} delete

8. Name of organizational liaison:
Note: The name of this liaison will be listed on the NAM's website unless you prohibit the NAM from listing this person's name. This person should be able to respond to direct inquiries if requested; the liaison does not need to be a subject matter expert or in a leadership position.* *This question is required.

9. Business title for organizational liaison: *This question is required.

10. Email address for organizational liaison: *This question is required. This question requires a valid email address.

11. Contact information for the organizational liaison will be posted on the NAM website to facilitate outreach and information sharing among network organizations. Please indicate whether or not you agree to share this information. *This question is required.

12. Contact information for the organizational liaison will be added to a network organization email distribution group that will receive newsletters and other updates from the Climate Collaborative. In addition, would you like to be added to the NAM’s climate and health public listserv to receive news on related events and publications? *This question is required.

13. Name of a communications or media contact at the organization, if different from the liaison specified:
Note: This information will not be shared publicly and will be used by NAM staff to share products and communications materials of the Climate Collaborative.

14. Email address for the communications/media contact:
Note: This information will not be shared publicly. This question requires a valid email address.

15. Please upload your organizational commitment statement as a Word or PDF document. Please refer to the submission guidelines above. *This question is required.

File: {{filename}} delete

16. Please affirm that you have read and agreed to the below Terms of Engagement for Network Organizations.

Terms of Engagement for Network Organizations for the National Academy of Medicine's Action Collaborative on Decarbonizing the U.S. Health Sector.

The Network Organization agrees to support the work of the Climate Collaborative by communicating and disseminating the Collaborative's materials and products.
At the request of the National Academy of Medicine, the Network Organization may be asked to provide expertise to the Climate Collaborative that cannot be obtained through existing member organizations.
The Network Organization may acknowledge its participation solely in the Climate Collaborative's Network Organizations. It may not represent that it is either a sponsor of the Climate Collaborative or a member of the Climate Collaborative, its steering committee, or one of its working groups.
The Network Organization acknowledges that it has no formal affiliation with the National Academy of Medicine, and as such, agrees to refrain from characterizing its association with the National Academy of Medicine or the Climate Collaborative as a "partnership" or any other legal or official relationship.
The Network Organization will not represent that any material produced by the Climate Collaborative, including any of its publications or public statements, has been produced by the Network Organization or that the Network Organization has otherwise been involved with the development of such material.
The Network Organization shall provide to the National Academy of Medicine, in advance of release, a draft of any press release (or other public statement) announcing or referencing its association with the Climate Collaborative, or other materials that use the National Academy of Medicine's name, trademarks, or logos. All such press releases, public statements, and materials are subject to prior written approval by the National Academy of Medicine.
The National Academy of Medicine has sole discretion to terminate a Network Organization's participation in the Climate Collaborative's Network Organizations and to remove the organization's commitment statement from the National Academy of Medicine's website without prior notice.

*This question is required.

I have read and agreed to the Terms of Engagement.