Form 4 Application for Pacific Islands Supplemental Funding

Form Approved

OMB No. 0920-0820

Exp. Date 12/31/2009

Application for Pacific Islands

Supplemental Funding for Tobacco Control,

Diabetes Prevention and Control, and Behavioral Risk

Factor Surveillance

Public reporting of this collection of information is estimated to average 30 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 Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0820)

Application:

A Project Abstract must be submitted with the application forms. All electronic project abstracts must be uploaded in a PDF file format when submitting via Grants.gov. The abstract must be submitted in the following format, if submitting a paper application:

• Maximum of 2-3 paragraphs.

• Font size: 12 point unreduced, Times New Roman

• Single spaced

• Paper size: 8.5 by 11 inches

• Page margin size: One inch

The Project Abstract must contain a summary of the proposed activity suitable for dissemination to the public. It should be a self-contained description of the project and should contain a statement of objectives and methods to be employed. It should be informative to other persons working in the same or related fields and insofar as possible understandable to a technically literate lay reader. This Abstract must not include any proprietary/confidential information.

Applications should address the following questions in a project narrative and be responsive

• What policy, environmental, and system changes including quitline have you already implemented (baseline)?

Performance will be measured by the detail the applicant describes of the implementation of current policies, environmental and system changes including quitline

• What do you hope to accomplish in this area by the end of 2 years?

Performance will be measured by how well the applicant describes the policy, environmental, and system change including quitline in the areas of nutrition, physical activity and nutrition.

• How do you plan to report performance measures to the CDC and provide ARRA reporting to Recovery.gov?

All recipients of ARRA funds are required to submit electronic quarterly reports. Performance will be measured by how well the applicant describes the plan to comply with ARRA reporting.

• What do you commit to develop or expand for 2 years that will lead toward the accomplishment of the recipient commitment?

Performance will be measured by how well the applicant describes the commitment towards what they plan to accomplish in 2 years.

• What technical assistance do you need from CDC to help you achieve this commitment?

Performance will be measured by the description of technical assistance needs

from CDC to achieve the proposed policies, environmental and system changes

including quitline.

A project narrative that includes responses to the recipient activities must be submitted with the application forms. All electronic narratives must be uploaded in a PDF file format when submitting via Grants.gov. The narrative must be submitted in the following format, if submitting a paper application:

• Maximum number of pages: 15. If your narrative exceeds the page limit, only the first pages which are within the page limit will be reviewed.

• Font size: 12 point unreduced, Times New Roman

• Double spaced

• Paper size: 8.5 by 11 inches

• Page margin size: One inch

• Printed only on one side of page.

• Number all narrative pages; not to exceed the maximum number of pages.

• Paper application should be held together only by rubber bands or metal clips; not bound in any other way.

The budget and budget justification will be included as separate attachments, not to be counted in the narrative page limit.

Additional information may be included in the application appendices. The appendices will not be counted toward the narrative page limit. This additional information includes:

• Curricula Vitae, Resumes, Organizational Charts, Letters of Support, and Indirect Cost Agreement.

• Action Plan that includes the selected evidence-based strategies; describes key activities; identifies anticipated policy outcomes; and includes SMART Objectives (Specific, Measurable, Achievable, Relevant, Time-Framed) for each intervention;