Form 0920-0909 DPRP Application Form

Form Approved
OMB No. 0920-0909
Exp. Date x/xx/xxxx

Apply for CDC Recognition
Diabetes Prevention Recognition Program (DPRP) Application Form
Public reporting burden of this collection of information is estimated to average 60 minutes per
response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining 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 Reports Clearance Officer; 1600 Clifton
Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0909).
*Indicates Required field

General Information
1. Type of Application *
Initial
Re-Apply
Previous OrgCode Assigned (Enter only if Re-Apply is selected)
2. Organization Name*
Upon approval of your application, this will be published in the DPRP registry and on the
program’s website.

3. Organization Physical Address (No P.O. Boxes)*

Upon approval of your application, this will be published in the DPRP Registry and on the
National DPP Locator.

Street Address*

Street Address Line 2

City*

State*

Zip Code*
+4

4. Organization Web Address or URL (Optional)

Upon approval of your application, if provided, this will be published in the DPRP registry and
on the program’s website.

Check URL Entry

NOTE: All web addresses must link directly to a location where participants can find
information about the organization’s CDC-recognized lifestyle change program and enroll in
the program. All web addresses published on the DPRP registry will be routinely reviewed for
compliance.

5. Organization Phone Number*

This is the number that participants, payers, and others should call to obtain information about
your program. Upon approval of your application, this will be published in the DPRP registry
and on the program’s website.
Phone Area Code - First 3 - Last 4 Ext:

6. Organization Type*

Choose the option that best describes the organization type. This refers to an organization’s
main headquarters location or main office:

(Drop-down menu)
Local or community YMCAs
Universities/Schools
State/Local Health Departments
Hospitals/Healthcare Systems/Medical Groups/Physician Practices
Community-Based Organizations
HRSA funded Federally Qualified Health Centers (FQHC), or Community Health
Centers, or Lookalike
Pharmacies/Drug Stores/Compounding Pharmacies
Indian Health Service/Tribal/Urban Indian Health Systems
Cooperative Extension Sites
Worksites/Employee Wellness Programs/Private Businesses
Senior/Aging/Elder Centers
Health Plans/Insurers
Faith-Based Organizations/Churches

Type of Delivery
7. Delivery Mode (check only one)*
In-person (if chosen, display basic application and the following check box:
Organization offers classes in states other than the state in which it is located)
Online (if chosen, display online questions)
Distance Learning (if chosen, display distance learning questions)
Combination (if chosen, display combination questions)

Questions Specific to Online Delivery
Online delivery is defined as “A yearlong National DPP LCP delivered 100% online for all
participants. Participants log into course sessions via a computer, tablet, or smart phone. The
organization must be able to track the participants’ progress through online course sessions. CDC
recommends requiring user IDs and passwords for course access. Live Lifestyle Coach interaction is

required and should be offered to each participant no less than once per week during the first six
months and once per month during the second six months.
Are you open to participants in every U.S. state or territory?
Yes
No
Do you offer participants an app to access your diabetes prevention program?
Yes
No

What will be the main mechanism/mode used for real-time coach interaction?
E-mail
Phone Call
Virtual Meeting Platform
Instant Messaging
Text
Other (please name)
Are modules kept locked to control for the intensity of the program as per Requirement 4 of the
DPRP Standards?
Yes
No
Do participants have access to modules once the week has passed?
Yes
No
Can participants skip modules?
Yes
No
Do modules include additional content outside the CDC-approved curriculum (i.e videos,
webinars, resources, recipes, articles)?
Yes (If yes is selected, then show this language “Please send the additional content to the
National DPP Customer Service Center at [email protected] for a 4-6 week
CDC review and approval process.”)
No
Can participants click on one session multiple times during a week?
Yes (If yes is selected, then show this language, “Please only record the date the session
is completed.”
No.
Is participant weight transmitted electronically?

Yes
No
Is participant physical activity data transmitted electronically?
Yes
No

Questions Specific to Distance Learning Delivery
Distance Learning delivery is defined as a yearlong National DPP LCP delivered 100% by trained
Lifestyle Coaches via remote classroom or telehealth. The Lifestyle Coach provides live delivery of
session content in one location and participants call-in or videoconference from another location.
Organizations that conduct make-up sessions via a delivery mode other than distance learning are still
considered to be delivering the program by distance learning.
Are you open to participants in every U.S. state or territory?
Yes
No
Which technology will you use to connect with participants?
Phone conferencing
A video platform such as Zoom or WebEx
Telemed/telehealth-hosted platform
Other (Write in)

Is participant weight transmitted electronically?
Yes
No

Is participant physical activity data transmitted electronically?
Yes
No

Questions Specific to Combination Delivery
Combination is defined as a yearlong National DPP LCP delivered as a combination of any of the
previously defined delivery modes for each individual participant by trained Lifestyle Coaches. A
combination modality can include the use of one modality such as in-person in the core phase of the
National DPP LCP and the use of a different modality such as online in the core maintenance phase.
It is a consistent delivery of two modalities across all participants. Or, aA combination modality can

include a consistent delivery approach of two modalities across each participant within the National
DPP LCP in a rotating manner (e.g., one session online and the next session in person; or one session
in person and the next via distance learning). In addition, the combination modality can be used to
deliver multiple delivery approaches to different participants within the same cohort. each cohort may
use a different combination of delivery modes (i.e., one cohort may use in-person and online and
another cohort may use in-person and distance learning). This accommodates mixed modalities where
each participant can choose a different delivery mode for each session as long as participants are not
selecting a single delivery mode for all sessions). A combination modality can also be the delivery of
two different modes within a single cohort, where some participants dial-in remotely consistently
(i.e., via distance learning), and other participants attend in-person consistently. The combination
delivery mode is not an option for organizations that wish to deliver entire cohorts by different
delivery modes (one cohort in-person and another cohort online) and then aggregate data from all
cohorts under one orgcode. In this case, organizations should apply for org codes for each delivery
mode they are using. Requirements for Lifestyle Coach interaction and the recording of weight and
physical activity minutes must be adhered to for the delivery modes being used. Organizations may
conduct make-up sessions via any delivery mode. It is important to note that using a combination
delivery code will prevent MDPP beneficiaries from receiving CMS reimbursement.
Which modes will you be using?
In-person
Online
Distance Learning
Combination

Program Coordinator
8. Program Coordinator Name*
Provide the name of the individual who will be the applicant organization’s Program
Coordinator. Provide a salutation [e.g., Mr., Mrs., Dr., Ms., Miss, other (please specify)], last
name, first name, middle initial, and academic credentials, if applicable [e.g., MD, RN, MPH,
MPA, PhD, other (please specify)]. The Program Coordinator’s information will not be included
in the DPRP registry.
Salutation Enter only if other is selected
Last Name* First Name* Middle Initial

Title*

9. Program Coordinator Contact Information*

Provide an email address for the organization’s Program Coordinator. DPRP staff will use this
information to communicate with the organization. All DPRP-related documents, reports, and
emails will go to the Program Coordinator.
Phone Number*
Email Address*
Verify Email Address*

Secondary Contact (if no secondary contact, check here

)

10. Secondary Contact Name*
Provide the name of the individual who will be the applicant organization’s Secondary Contact,
if applicable. This person would be contacted in the event an organization’s Program
Coordinator cannot be reached for routine communication. Provide a salutation [e.g., Mr., Mrs.,
Dr., Ms., Miss, other (please specify)], last name, first name, middle initial, and academic
credentials, if applicable [e.g., MD, RN, MPH, MPA, PhD, other (please specify)]. The
Secondary Contact’s information will not be included in the DPRP registry.
Salutation Enter only if other is selected
Last Name* First Name* Middle Initial
Title*

11. Secondary Contact Information *
Phone Number*
Provide the email address of the organization’s Secondary Contact, if applicable.
Verify Email Address*

Data Preparer (if no data preparer, check here
12. Data Preparer Name*

)

Provide the name of the individual who will be the organization’s Data Preparer. This can be
either the Program Coordinator or the Lifestyle Coach if a third person is not designated at this
time. Provide a salutation [(e.g., Mr., Mrs., Dr., Ms., Miss, other (please specify)], last name,
first name, middle initial, and academic credentials, if applicable [(e.g., MD, RN, MPH, MPA,
PhD, other (please specify)]. The Data Preparer’s contact information will not be included in the
DPRP registry.
Salutation Enter only if other is selected
Last Name* First Name* Middle Initial
Affiliation*
The contact person’s affiliated organization. If none, enter "self".

13. Data Preparer Contact Information*
Provide the email address of the organization’s Data Preparer. DPRP staff will use this
information to communicate with the organization about data submission issues, if required.
Phone Number*
Email Address*
Verify Email Address*

Program Delivery Information
14. Class Type (check all that apply)*
Public
Employees
Members
Other (write in target audience served such as American Indians/Alaskan Natives,
patients, clients, etc.
15. Lifestyle Coach*
The primary training entity the applicant organization will use or has used to train their main
Lifestyle Coaches.
A training entity on the CDC website
A private organization with national reach
A virtual organization with national reach

A Master Trainer (MT) who completed an MT program
Name of training provider*
NOTE: The full list of CDC Training entities are found here:
https://www.cdc.gov/diabetes/prevention/lifestyle-program/staffing-training.html
16. Curriculum.*
If you select Other Curriculum, you must submit your curriculum files.
2016 PreventT2 - English
2016 PreventT2 – Spanish
2016 PreventT2 – English and Spanish
2012 National DPP curriculum – English
2012 National DPP curriculum – Spanish
2012 National DPP curriculum – English and Spanish
Native Lifestyle Balance-Preventing Diabetes in American Indian Communities
Other Curriculum

Certification of Application:
Electronic signature. Submitting the application asserts that the organization has thoroughly
reviewed the CDC Diabetes Prevention Recognition Program Standards and Operating
Procedures and is voluntarily seeking participation in the CDC recognition program. The
organization agrees to comply with all the recognition criteria contained in the DPRP
Standards, including the transmission of data to CDC every 6 months from the CDC-assigned
effective date, for the purpose of program evaluation, continuing recognition, and technical
assistance. (Enter the name and title of the authorized representative, the organization name,
and date.)

Once an organization’s application has been reviewed and approved, the DPRP will send an
email to the organization’s Program Coordinator indicating that the organization has been
granted pending recognition. This email will include the unique organization code assigned by
the DPRP, the organization’s effective date (which determines the date the organization’s

evaluation data are due to the DPRP), and instructions for data submission. Once approved, the
organization will be listed on the DPRP Registry. This process takes approximately 15 days.
If an organization submits an alternate curriculum for review and approval by CDC, an initial
email indicating receipt will be sent. Organizations should allow 4-6 weeks for review and
approval of the application and assignment of an organization code. If an alternate curriculum is
not approved by CDC, the application will not be approved. CDC will describe in writing the
reasons why a curriculum is not approved and allow the organization an opportunity to correct
any issues and reapply for recognition once the curriculum is amended. Any questions about an
organization’s application status should be directed to the National DPP Customer Service
Center.