Application

Thank you for participating in the Patient Safety Prize!

We recommend reading all requirements for this application before you begin and encourage you to review the Rules and FAQ, as well as the scoring rubric that will be used to assess all valid applications.  

This application form saves automatically and the status of your application is available to view on your dashboard. You have the option to request an automated confirmation email after clicking Submit – be sure the checkbox is clicked to opt into this email when the confirmation message appears.

Your submission may be shared with five of your fellow applicants as part of Peer-to-Peer Review, five Evaluation Panel members, the Selection Committee, the Patient Safety Prize team, and others at the discretion of the Patient Safety Prize team during the evaluation process. Portions of your applications may be published online and may be shared with the general public to promote your proposal or to highlight results. Those portions may include, but are not limited to: Lead Organization, Lead Organization Website, Solution Title, Solution Statement, Executive Summary, Video Pitch, and Solution Description.

Responses to this submission form must be in English. This provides consistency across all submissions during our review process and reduces the risk of misinterpretation or translation error. 

Prior to submission:

• Confirm the information provided on the Registration Form is correct (go to Submissions and select Registration Form).
• Be sure to review your submission as it will appear after it has been submitted (click Preview next to Submit). 
• When you have completed all requirements, you will be able to submit the application form. Once you have submitted, you will no longer be able to make changes.  

Submit your application no later than 5:00 PM Eastern Time on Tuesday, April 7, 2026. Contact questions@patientsafetyprize.org with questions or technical issues. 

All fields are required unless otherwise noted.

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A. QUICK PITCH

Make a strong first impression with a succinct and compelling overview of your solution. In this section, avoid using first-person language, acronyms, jargon, or complex language that may be difficult for the general public to comprehend. Your responses to this section may be shared publicly in a variety of online settings.

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Solution Title (up to 10 words)

Provide a title for your proposed solution that easily identifies and distinguishes it from others.

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Solution Statement (up to 25 words)

Provide a short, one- to two-sentence description of your proposed solution.  

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Executive Summary (up to 75 words)

Provide a concise summary of the most compelling aspects of your proposed solution. This should be a stand-alone statement of the problem, solution, and intended results. It should not require any other context to clearly explain what you are seeking to accomplish.  

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B. VIDEO PITCH

You are required to submit a video that captures your solution and describes why it should be funded. The video is an opportunity to showcase your passion and to pitch your story in a succinct format. We want you to share your vision in a way that is different from the written proposal. This DOES NOT need to be a professionally produced video – a video shot on a smartphone is acceptable. 

To complete this requirement, upload a digital film using YouTube. Video submissions must follow these guidelines or else it will render the application ineligible:

• Ninety (90) seconds in length maximum. 
• In English, or if in another language, subtitled in English.
• Must be captioned. See instructions on how to caption YouTube videos here. 
• Excludes images of identifiable children (under age 18) without express parental consent. 
• Excludes copyrighted material (including, but not limited to, music) for which you do not have a license. 
• Set the Privacy Settings on your video to Public or Unlisted – do not set them to Private. When setting as Unlisted, only those with the URL – such as the Patient Safety Prize team, the Evaluation Panel members, and the Selection Committee – will be able to access and view the video.
• Check to make sure embedding is turned on.
• Be sure all these settings are in place throughout the duration of the competition.

Here are general suggestions for delivering a high-quality video pitch:

• Introduce yourself and your organization(s) or team. 
• Explain your solution, its impact, and what is unique about the way it addresses the problem. 
• Describe how you plan to measure success and achieve meaningful impact at the community-level. Do not simply read a slide deck – instead, make an effort to connect with your audience of Peer Review and Evaluation Panel judges.

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C. THE TEAM

Provide a basic understanding of the leadership, structure, and capabilities of those working on this solution. Should you receive funding, you must designate a Lead Organization responsible for taking accountability for those award funds and any required reporting, as well as providing sustained project direction, control, and supervision. The Lead Organization was identified during registration. If the Lead Organization has changed, please select Registration Form from the Submissions menu to update the Lead Organization information. 

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Partners

We welcome applications from teams that include multiple organizations and reflect cross-sector partnerships. If your team consists of two or more organizations, list them using the legal name of each partner. If your team does not consist of two or more organizations, enter “Not applicable.”

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Partner Agreement 

An agreement, such as a Memorandum of Understanding (MOU), may be requested from teams consisting of two or more organizations that are responsible for the proposed solution and that would receive a portion of funding from the competition. If your team does not consist of two or more organizations, select “Not applicable.” 

• Team of two or more organizations with a fully-executed MOU 
• Team of two or more organizations intending to submit an MOU if requested later in the review process 
• Not applicable

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Team Structure (up to 150 words) 

Describe the roles, responsibilities, and contributions of each key team member/partner. Explain how the team will work together, including any reporting structures between the partners and Lead Organization. 

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Team Biographies (up to 200 words)

Introduce us to at least one and up to three individuals who will oversee and be responsible for the success of the project, including any external partners integral to implementation. For each, provide a first/last name, title, and affiliation (if applicable), and a brief biographical statement. Emphasize the expertise and/or credentials that are most relevant to this project, as well as any personal experience with the challenges the solution aims to address. Please include links to key team member/partner LinkedIn profiles. 

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Track Record & Capabilities (up to 150 words)  

Describe the past success of your team’s leadership, members, and collaborators or partners. If relevant, include details about how and why the collaboration was formed. Explain how your team is uniquely positioned with the right capabilities, experience, technical expertise, and commitment to execute your project. Be sure to include core competencies and how they apply to your project, any relevant past endeavors or experience, and any other additional details that support your ability to deliver results.

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D. THE CHALLENGE

Demonstrate your understanding of the problem you aim to solve. 

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Challenge Statement (up to 150 words)

Set the stage for your proposal by illustrating your understanding of the patient safety problem you are committed to solving as it relates to your chosen solution category: Empowering Health Literacy for Safer Patient Care, Innovating to Eliminate Medication Errors, or Promoting Fall-Free Futures. Identify real and potential challenges and describe specific needs that your solution will address.

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Local Conditions & Existing Landscape (up to 250 words)

Describe the local conditions in and around where you intend to implement your solution. This is your opportunity to showcase that you’ve taken time to understand any issues that are important and/or unique to the communities you aim to serve, as applicable. Briefly describe other efforts aimed at addressing this problem and, if applicable, other organizations or projects that are most similar to your work. Explain how your team and proposed solution fit into, build, and/or improve on this landscape. 

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E. THE SOLUTION

The Patient Safety Prize seeks innovative proposals that improve patient safety through community informed outcomes in the following areas:

• Empowering Health Literacy for Safer Patient Care
• Innovating to Eliminate Medication Errors
• Promoting Fall-Free Futures

llustrate your approach and the benefits your solution will deliver. Emphasize how your solution aligns with the criteria used to assess each valid application (see scoring rubric).

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Solution Category

Solution Category was selected during registration. If this has changed, please select Registration Form from the Submissions menu to update.

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Solution Stage 

Select one option that best describes the project stage for your proposed solution. Be sure to review the scoring rubric to understand how applications will be evaluated.  

• Research & Ideation: In the process of developing a new approach to addressing the issue but has not tested the approach. 
• Proof of Concept: Has been implementing the strategy for a small number of targeted stakeholders and/or at a small scale. 
• Scaling: Has evidence of impact and is expanding and adapting the strategy, but has yet to achieve large-scale implementation.
• Operating at Scale: Has evidence its strategy achieves impact and is delivering the solution at scale, but further iteration / evolution of the solution may increase impact. 

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Solution Description (up to 250 words)

Describe your solution and the ways in which it addresses patient safety, the relevant solution category, and your Challenge Statement. Provide an overview of key stakeholders and introduce the measurable impact and benefits to these communities. Note: Later in the application you will have additional opportunities to describe beneficiaries and intended impact in more detail.

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What is the scale of your solution?

Select the option that best describes your solution.  

• National: Solution will benefit communities in all states
• Local: Solution will benefit a specific community or communities in one or more states

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What location(s) will your solution serve?

Provide the following information for at least one and up to five of the primary locations that will be served by your solution. If your solution is national, you may select “All States” and “All Counties” from the dropdown menus for State and County and enter “Not applicable” for City and Zip Code. If your solution is statewide, you may select “All Counties” from the dropdown menu for County and enter “Not applicable” for City and Zip Code. You will have the option to further describe impacted geographies under Section F. Beneficiaries.

State

County

City

Zip Code

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Innovation (up to 150 words) 

Explain how your solution diverges from, enhances, and/or reinforces existing methods/practices. Emphasize unique aspects of your solution and why you believe it will be more effective, efficient, or impactful than existing efforts to address the problem.

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Integration & Regulatory Engagement (up to 200 words) 

Further illustrate your understanding of the current environment where you have chosen to implement your solution, including currently relevant systems and local conditions which affect your plans. Address issues that might concern stakeholders, such as data security, mitigation of bias, safety, privacy, stability, and/or interpretability. If you foresee needing to engage with or depend on governmental authorities in the location(s) above to implement your solution, describe whether contact has been established and level of support currently provided. If applicable, explain how you’ll build upon and integrate within existing systems and infrastructure. If this is not relevant for your solution, enter “Not applicable.” 

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Data & Intellectual Property (up to 150 words)

Describe the data and data sources your solution will need to deliver its intended results, as well as the status of your access to that data. Explain any issues related to intellectual property (IP) that underlie your solution. Identify owner(s) of the IP. If you are building on third-party or off-the-shelf technology, detail the permissions you have secured to utilize that technology and the nature of those entities' access to new data generated. Describe how you will make the use of any IP for the purposes of scaling your proposed solution during the two-year project period. What challenges do you anticipate (for example, data privacy, regulatory compliance, etc.) and what is your route to overcoming them? If this is not relevant for your solution, enter “Not applicable.” 

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User Experience (up to 150 words)

Describe the journey for up to three (3) different types of potential participants of the proposed solution. This may include the main flow of actions for primary users/intended audiences, as well as any alternative use cases the solution can support. Include plans to promote your solution to the intended audiences to help ensure access to your project. If this is not relevant for your solution, enter “Not applicable.” 

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Project Visual (up to three pages) 

Upload a single PDF that includes a visual representation of your project, technical features, and technical expertise described above. This may include, but is not limited to: user interface, illustrations, schematics, images, graphs, diagrams, maps, flow charts, organizational charts, or other visuals to help reviewers to better understand your team and proposed approach. The PDF should not exceed 10MB and a total of three pages, and should not contain additional text explanations or be used to circumvent word counts in this application. Some brief labels and/or basic text descriptions are permitted. Any pages beyond the three-page limit, as well as unrelated content to this specific question, will render the application ineligible. 

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F. BENEFICIARIES

Tell us more about where your solution will focus its impact and the communities that will benefit. 

What gender identity/identities does your solution serve? 

Select all that apply. 

• Female 
• Male 
• Non-Binary 

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What age group(s) does your solution serve? 

Select all that apply.  

• Children – Preschool (0-4 years)
• Children – Elementary School (5-10 years)
• Youth – Middle School (11-13 years)
• Youth – High School (14-17 years)
• Young Adult/College (18-22 years)
• Adult (23-59 years)
• Senior (60+ years)
• Not Age Specific

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What additional populations does your solution serve? 

Select all that apply.  

• Members of LGBTQ+ community or allies
• Immigrants
• Veterans
• Individuals with disabilities
• Other
• Not applicable

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Beneficiary Description (up to 200 words) 

Describe the people/communities and geographies that your solution is intended to benefit. Explain your priority population(s), as well as any secondary or other populations who may engage with and/or benefit from the solution.

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Beneficiary Engagement (up to 200 words) 

Describe your approach to responding to existing and expected needs of the populations described above. Identify which stakeholders you have engaged so far and how you will continue to engage relevant decision makers, beneficiaries, and other stakeholders to ensure your solution successfully achieves your goals. Articulate any negative externalities or costs/burdens absorbed by beneficiaries.

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Stakeholder Engagement (up to 150 words) 

To be effective, solutions may need support or partnership from others – government, investors, technology partners, community leaders, etc. Demonstrate your understanding of the key stakeholders necessary for your work to be effective and describe plans to engage them on an ongoing basis to ensure long-term success. Articulate any costs/burdens that stakeholders may be expected to absorb. 

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Underserved Populations & Accessibility (up to 150 words)

We expect teams to be strategic about working with a range of stakeholders and beneficiaries, and to actively plan for and include the most marginalized or vulnerable residents in project design, planning, and ongoing work. Explain how you will ensure that the design and implementation of your solution authentically embraces accessibility and belonging across all populations.  

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G. THE IMPACT

Demonstrate how your solution will achieve results, including evidence that supports your approach.

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Metrics & Results (up to 250 words) 

Identify all goals, specific metrics, and/or SMART objectives associated with your proposed solution during the two-year project period. Goals, metrics, and objectives must be measurable and should include, but are not limited to, the specific percentage increase/decrease, projected numbers of participants or impacted recipients reached, the number of months or years required to achieve the objectives, and so forth. Describe your methodology for measuring the overall performance of the proposed strategy and outline the means through which you will track results or milestones to indicate success.

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Reach & Scalability (up to 200 words)

Does your solution currently reach people and if so, how many on an annual basis? If your solution has not been activated, list the total number of people you plan to reach on an annual basis, share your vision for how you plan to meet your proposed goal and information on any specific geographies you plan to target or eventually grow into. Share your vision for expanding your reach and plans you have to expand your solution to benefit more people, including any plans to promote your solution to enable broader impact. If you expect a significant change in your reach in the coming two years, describe the factors that will affect this change. You may compare your current reach with how many you project to be reaching two years from now, including your rationale for this projection.  

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Long-term Impact (up to 150 words)

Describe the impact your solution will have beyond the two-year project period. Share your goals for long-term success and illustrate your vision for how your project will evolve in the future.

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Evidence of Effectiveness (up to 150 words) 

Provide evidence to show that the solution will work. Present any internal (e.g., informal studies, observations, or other indicators of change) or formal evidence, including any evaluation results. If you do not have evidence of impact of your own solution, can you point to research-backed practices on which your solution is based, or analogous solutions achieving meaningful impact that you think your solution may similarly achieve? Note: You may include a bibliography below under References.

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Evidence Type 

Select one option that best describes the level of evidence supporting your proposed solution. 

• There is a theoretical logic model for the strategy, but it has never been implemented. 
• Strategy has been implemented, but team has not (yet) formally tracked outcomes or collected measurable effect or beneficiary feedback (as relevant). 
• Formally collects and documents qualitative and/or quantitative feedback to assess progress but has not conducted a formal assessment. 
• Has conducted internal evaluations or outcome assessments. 
• There has been at least one external evaluation of outcomes. 
• There has been an external assessment of impact (e.g., RCT; quasi-experimental design; contribution analysis; collective impact).

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References (up to 100 words)

If you included citations for Evidence of Effectiveness, provide a bibliography with a corresponding bracketed number [#] for each citation. There is no specific required format for citations. You may also offer a list of resources that may be used to validate general claims made in your application. If not applicable, enter “Not applicable.”

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Marketing & Communications (up to 100 words) 

Describe your plans to promote your solution and/or share your results, key findings, lessons learned, and other helpful information with others. Explain how you will publicize this award and include any national or local media relationships the Lead Organization may utilize.

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H. PROJECT PLAN & BUDGET

Illustrate your plan and the resources required to successfully implement your solution.  

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Plan & Timeline Narrative (up to 150 words)

Offer a general overview of your implementation plan over the course of a two-year project period. Include key activities and milestones to help track and measure success.  

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Detailed Timeline

Provide a detailed implementation plan and timeline over the course of a two-year project period. Milestones and dates noted below should reflect and clarify your general explanations provided in Plan & Timeline Narrative above and include more specific descriptions and key dates.

Note that a maximum of 30 rows can be added below. The Total Plan Duration must be less than or equal to 730 days, which equals two years.

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Risk Mitigation (up to 100 words)

Explain how you will ensure your solution is feasible. Describe the main risks your solution could fail, as well as any unintended consequences, and your plan to address them. Discuss your experience and capacity to manage technical and/or operational barriers.

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Budget Narrative (150 words)

Offer a general overview of how you will use the $1.5 million award, including projected needs by category. You may include any explanations of existing resources you have already secured.

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Detailed Budget

Provide a detailed budget for how the $1.5 million award would be spent. Funds identified in this table should reflect and clarify your general explanations provided in Budget Narrative above and include more detailed cost categories that support your plans and intended outcomes. Avoid any general line-item descriptions such as “Miscellaneous.”

While general operating support is not allowed, we recognize applicants may have overhead costs that are not directly attributable to the proposed project but are necessary for implementation. We reserve the right to review and adjust the amounts allocated for indirect expenses. We will consider paying for these indirect costs up to a maximum of 15% of direct project or activity costs. Ensure that any indirect costs are accounted for in your budget. Review the Rules for more information about ineligible expenses and indirect costs. 

The budget must account for the full $1.5 million award.  

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Total Projected Costs 

Provide the estimated total costs (in US dollars) to successfully implement your proposed solution over a two-year period. 

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Total Resource Requirements (up to 100 words)

If your project requires more than $1.5 million (USD), explain how you have secured (or plan to secure) the balance of any necessary funds and provide an overview of how those funds will be used. If your total projected costs do not exceed $1.5 million (USD), enter “Not applicable.”

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Other Funders (up to 75 words) 

List other key funders and amount of funding secured to date for the proposed solution, including in-kind support. If there are no current commitments for the solution, enter “Not applicable.”

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Contingency (up to 150 words) 

The Patient Safety Prize will provide Honorable Mention awards of $250,000 to up to two participants. Explain any adjustments to the proposed plan and impact should you receive a $250,000 Honorable Mention award, and how the project may be impacted if a $1.5 million award is not secured. Describe any potential to leverage additional resources to realize, sustain, and/or scale your project.

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Sustainability (up to 100 words) 

Describe plans to leverage additional resources to sustain and/or scale your approach beyond the two-year project period. 

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Other Considerations (up to 100 words) 

This is your opportunity to raise any other considerations, emphasize or expand upon a previous point, or provide new information, as necessary. Note: Evaluation Panel judges are instructed to avoid online research and/or review of links that may be provided as part of this submission – we recommend you include any key considerations and important information within your responses to this application form. 

I. ADMINISTRATIVE INFORMATION

Provide additional information about the Lead Organization.

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Lead Organization Identification Number (up to 5 words)

Provide the identification number provided by the Lead Organization’s taxing authority (e.g., the Internal Revenue Service). If this is in progress, insert “Pending approval.” 

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Annual Operating Budget 

What is the annual operating budget (USD) of the Lead Organization? 

• Less than $1 Million 
• $1.0 to 5.0 Million 
• $5.1 to 10 Million 
• $10.1 to 25 Million 
• $25.1 to 50 Million 
• $50.1 to 100 Million 
• $100.1 to 250 Million 
• $250.1 to 500 Million 
• $500.1 to 750 Million 
• $750.1 Million to $1 Billion 
• $1 Billion + 

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Number of Full-time Employees 

How many full-time employees (FTE) does the Lead Organization employ? 

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Number of Part-time Employees

How many part-time employees does the Lead Organization employ? 

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Financials - Upload

If you are selected to participate in future phases of the competition, we will require information necessary to understand the financial health of the Lead Organization. Please upload audited financial reports, 990’s, and/or certified financials for the past two (2) years.

If you do not currently have this financial information, please attach no more than a one-page explanation and confirmation that you will be able to provide this information should you be selected as a finalist.

Please upload this financial information in a single PDF file that does not exceed 10 MB.

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Financials - Confirmation

Select YES below if you have uploaded audited financial reports, 990’s, and/or certified financials for the past two (2) years.

Select NO below if you have uploaded a one-page explanation for not providing financials at this time and confirmation that you will provide these financials should you move on as a finalist.

• Yes
• No

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Prior Funding (up to 50 words)

In the past five years, has the Lead Organization received any funding from Elevance Health or its affiliated companies (Anthem Blue Cross, Anthem Blue Cross and Blue Shield, Amerigroup, Carelon, Simply Healthcare, Unicare, and Wellpoint)? If yes, describe below. If no, enter “Not applicable.”

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J. ADDITIONAL INFORMATION

If your team is invited to participate in any future phases of this competition, you may be asked to provide additional information (refer to the Rules and Timeline), including but not limited to: 

• Pitch or demo of the proposed solution
• Your acceptance of a separate award agreement with the Elevance Health Foundation
• Additional information about your organization
• A more detailed budget, project plan, project timeline, and evaluation plan, including key metrics
• Additional information about charitable purpose and compliance with private benefit rule
• Fully executed Memorandum of Understanding (MOU) with any partners  
• Tax determination letter, if applicable
• Audited financial statements, 990s, and/or certified financials    
• Articles of Incorporation, Charter, or similar documentation  
• Evidence of efficacy of the solution, including technical capabilities if applicable
• Evidence of additional funding and resources secured to implement the proposed solution
• Existing policies, if any, addressing conflicts of interest, whistleblower, internal controls, anti-money laundering, intellectual property, code of conduct, ethics, gifts, and any similar policies governing the Lead Organization and/or partners
• If selected as a Finalist, updates and additional information on the proposed solution 
• If selected for an award, required reporting as outlined in the award agreement

The Elevance Health Foundation reserves the right to perform background checks on key individuals associated with the proposal, and the refusal by key individuals to provide necessary authorizations will be a reason to reject any application for further consideration. Background information and the results of any background checks will be kept confidential.