Form 3 Supplemental Funds Application

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Application

Supplemental Funding for Healthy Communities, Tobacco Control,

Diabetes Prevention and Control, and Behavioral Risk

Factor Surveillance

Public reporting of this collection of information is estimated to average 40 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)

Application Content for Component I

The narrative should address activities to be conducted over the entire project period of this supplemental award, and follow the order of the sections provided below. The base and population specific funding application page limit is 25 pages, not including appendices and curriculum vitae.

1. Implementation of social, environmental, policy and systems approaches at the state level

1. Approach and rationale: This section should describe the overall approach to improving the statewide environment related to obesity, physical activity, nutrition, and tobacco as a result of this funding. The narrative should briefly assess and identify the current status of MAPPS intervention strategies in the state, and identify and justify each statewide policy initiative proposed for implementation based on that analysis. The justification should at a minimum address the factors in Appendix B: Sample Policy Analysis Worksheet.

2. Implementation Plan: For each statewide policy initiative, describe detailed implementation activities to be undertaken during the project period, including milestones and timelines for achieving intervention implementation. A suggested format can be found in Appendix C: Sample Implementation Work Plan. Work plans should at a minimum address the following:

1. Goals

2. Objectives

3. Action steps

4. Milestones for implementation of action steps and progress on objectives

5. Key Partners

6. Evaluation strategies, including key output and outcome measures related to the action steps and objectives, and data source for collection of these measures.

2. Program Readiness, Oversight and Management

This section should briefly describe the proposed program infrastructure that will be required to implement the work plan. Applicants should address staffing needs for the State Health Department and where appropriate staff support provided to key partners (such as the state education agency) to carry out the goals of the program. Clearly identify the creation of new positions, as well as positions that will be retained as a result of this funding, and describe the linkages to existing obesity, nutrition, physical activity, and tobacco control programs. Identify commitment from the Governor’s Office to hire or retain appropriate staff and to support program staff travel to attend required training.

3. Statewide Support for Community Level Change

This section should describe current and needed linkages with local community initiatives to include, when funded, communities that are awarded Recovery Act funding through the CPPW Initiative, and the activities that will be implemented to support local efforts. Describe training, programmatic support and consultation needs and steps to address those needs. Describe communication and marketing approaches that will be used to create a supportive statewide environment to facilitate the achieving the goals of the proposal. Include detailed implementation work plans where appropriate. States should coordinate the efforts proposed here with any community activities funded as part of this initiative in large cities, urban areas, tribal areas or state-coordinated small cities and rural areas.

4. Surveillance, Program Monitoring, & Reporting

This section should describe activities and steps to fulfill program monitoring and reporting requirements including development of new, or enhancements to existing, systems for surveillance and measurement of policy and environmental change activities as described in the recipient activities. Applicants should clarify commitment to report Recovery Act output and outcome performance measures and other Recovery Act reporting requirements, and participate in Recovery Act or other national evaluation activities, including participation in case study evaluation if selected as a case study site.

5. Sustainability

This section should describe plans for working with partners to sustain the impact of program efforts beyond the project period including sustaining and pursuing non-federal sources of funding. This section should also describe activities and plans to ensure the intended and sustained effect of the policy changes after Recovery Act funding has ended.

6. Fiscal Management

This section should describe steps to ensure responsible and effective use of the funds in accordance with the requirements of receiving Recovery Act funding. Include provisions for capacity to track and monitor expenditures separate from other federal funding streams and development and use of reporting systems to meet the online reporting criteria and timelines as stated in Recovery Act and in this supplement.

Budget and Justification

States are encouraged to follow recommended guidance for completing a detailed justified budget found on the CDC Web site, at the following Internet address:

http://www.cdc.gov/od/pgo/funding/budgetguide.htm.

III. Component II – Competitive Special Policy and Environmental Change Initiatives

Eligible applicants will have the opportunity to apply for additional funds to be awarded on a competitive basis. Additional funds will be awarded to State Health Departments that demonstrate readiness to implement special large scale, statewide policy or environmental change initiatives within the overall intent of this cooperative agreement. These additional activities must align with the above stated recipient activities, support the local communities including but not limited to communities that will be awarded Recovery Act funding under the CPPW Initiative, and are expected to demonstrate a policy or environmental change that may have a substantial impact on the burden of obesity, physical inactivity, poor nutrition or tobacco use in the state. Additional guidance can be found in the Application Content section.

1. Implement at least one or more high-impact additional policy, environment or system change strategy to achieve health equity/eliminate health disparities in the area of physical activity, nutrition, or tobacco or a combination thereof for development, implementation and evaluation over the 2 year project period.

1. Implementation activities should be related to state level strategies that will support the interventions listed in the “MAPPS Intervention Strategies for State and Territory Policy, Environmental Change” table provided in Attachment A. States may also choose policy and environmental interventions that are considered “Best Practices” in the field. If choosing these interventions the state must justify why it is considered a best practice, how the state’s efforts will add to the knowledge of practice-based and evidence-based strategies, and how it will further national efforts to address these risk factors.

2. Strategies selected should be best practices or evidence-based with a thorough analysis of the source of burden in the state, current state of policy and environmental supports, potential for reach, impact, successful implementation and to address gaps that exist.

3. Applicants are expected to propose strategies that are most likely to affect statewide burden and therefore, where appropriate, emphasize plans to achieve health equity.

4. The level of funding awarded under competitive “Special Policy and Environmental Change Initiative” will depend on the strength of the proposed strategy and likelihood of affecting the burden in the state, as well as impacting national obesity and tobacco trends either through improved health behaviors in the state, through innovative strategies for implementing high-impact policy and environmental change, or through major contributions to the practice-based evidence for policy and environmental strategies. Funding decisions will be determined through an objective review process. Applicants must provide detailed implementation plans and projected outcomes.

Application Content for Component II

Applicants requesting additional support to implement activities under Recipient Activity Component II – Competitive Special Policy and Environmental Change Initiatives should submit an additional narrative and budget request as described under Special Policy and Environmental Change Initiative below. The application page limit for Component II is an additional 20 pages.

Special Policy and Environmental Change Initiatives

This optional section of the proposal will be reviewed separately by appropriate subject matter experts working in the field of obesity, nutrition, physical activity, and tobacco. Note: Proposed initiatives are limited to what is listed in Appendix A. Proposals for strategies not found in Appendix A may be considered depending on the strength of the analysis and justification for pursuing that initiative. For each special policy and environmental change initiative proposed provide the following:

1. Burden Analysis: Clearly and succinctly describe the source of disease burden in the state for the targeted risk factor i.e., obesity, physical inactivity, poor nutrition or tobacco use (or the combination addressed by each selected strategy). This should include analysis of the policy and environmental factors found to be contributing most to the population-level burden of disease, and the likely impact of addressing those factors as they effect both on disparately impacted populations and the broader state population to reduce that the statewide burden.

2. Rationale: Describe rationale for selection of this initiative by addressing all of the following:

1. Description of readiness to implement special large scale, statewide policy or environmental change initiatives within the overall intent of this cooperative agreement;

2. Evidence that selected strategies further implement stated goals and objectives in a state-approved state strategic plan that was developed with partners and stakeholders and that focuses on policy and environmental change strategies to address any or all of the risk factors, i.e., obesity, physical inactivity, poor nutrition or tobacco use;

3. Results from small scale initiatives that are ready to be expanded to larger scale initiatives;

4. Linkage of proposed strategy to reduction in burden;

5. Justify the initiative by addressing the factors in Appendix B: Sample Policy Analysis Worksheet.

3. Implementation Plan: Describe detailed implementation activities to be undertaken during the project period. Work plan should at a minimum address the following:

1. Goals

2. Objectives

3. Action steps

4. Milestones for implementation of action steps and progress on objectives

5. Key Partners

6. Evaluation strategies, including key output and outcome measures related to the action steps and objectives, and data source for collection of these measures.

4. Program Readiness, Oversight and Management

This section should briefly describe the additional program infrastructure that will be required to implement the activities proposed under “Optional Activity G.” Applicants should address staffing needs for the State Health Department and where appropriate staff support provided to key partners to carry out the goals of the special initiative. Clearly identify the creation of new positions, as well as positions that will be retained as a result of funding this initiative as required by the Recovery Act. If additional staffing is not necessary to implement this special initiative, describe how oversight and management will be addressed by the infrastructure proposed under the non-competitive proposal.

e. Surveillance, Program Monitoring, & Reporting

This section should describe activities and steps to include the special policy initiative in all program monitoring and reporting requirements described in the recipient activities for the non-competitive portion of this announcement. Applicants should clarify commitment to submit Recovery Act output and outcome performance measures, and participate in additional national evaluation activities related to “Optional Activity G.”

f. Budget and Justification: A separate line item budget and justification must be submitted for each initiative proposed under this section. States are encouraged to follow recommended guidance for completing a detailed justified budget found on the CDC Web site, at the following Internet address: http://www.cdc.gov/od/pgo/funding/budgetguide.htm.