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>STEP 1 >STEP 2 >STEP 3a >STEP 3b >STEP 3c >STEP 3d >STEP 4 >STEP 5 >STEP 6 STEP 1: PROGRAM SPONSORSHIP NOTE: An asterisk (*) indicates a required field. Formal name of the incentive and/or reward program initiative (if applicable) Formal name  Names of the program sponsor(s) and the parent organization of that sponsor (if applicable) Program sponsor(s) (separate multiple sponsors by comma)*  Parent organization  Contact information for designated program contact (if you have multiple sponsors, please only designate a primary contact) Name*  Title  Organization*  Email*  Phone  Type of sponsoring organization(s) Employer(s) (check all that apply)  Single employer Multiple employers Employer-only coalition Multiple Sponsor Types (check all that apply)  Employer/health plan coalition Employer/hospital coalition Employer/health plan/hospital coalition Other multi-stakeholder coalition  Specify  Government(s) (check all that apply)  Local  Specify  State  Specify  Federal  Specify  Health Plan(s) (check all that apply)  Single HMO Single PPO/other Multiple health plans Other (check all that apply)  Taft-Hartley plan Other  Specify  Source of funding associated with program set-up costs Funding source*  Grant-funded  Specify funding organization  Funded by program sponsor(s) Combination grant/sponsor  Specify funding organization  Other  Specify  If applicable, specify the percent contributed by sponsor and percent contributed by grant organization % Sponsor  % Grant  % Other  Approximate dollar amount for program set-up costs  Source of funding associated with program operations costs Funding source*  Grant-funded  Specify funding organization  Funded by program sponsor(s) Combination grant/sponsor  Specify funding organization  Other  Specify  If applicable, specify the percent contributed by sponsor and percent contributed by grant organization % Sponsor  % Grant  % Other  Approximate dollar amount for program operations costs  Start date & end date of the program Start(MM/DD/YYYY)*  End (enter date or indicate "ongoing")(MM/DD/YYYY)*

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