Form 0990-0390 2022 REACH Lark Award Application

Form Approved

OMB No. 0990-0390

Exp. Date 04/30/2023

2022 REACH Lark Award Application

January 5, 2022

Thank you for your interest in applying for the 2022 REACH Lark Galloway-Gilliam Nominations for Advancing Health Equity (2022 REACH Lark Award). Please email your completed form to [email protected]. Applicants may also include supplemental documentation references, if applicable. DNPAO will accept applications through Thursday, March 2, 2022.

For this application form, the applicant refers to each individual or organization/community coalition who submits and application or nomination. The nominee refers to each individual or organization/community coalition who is nominated, including both self-nominated nominees and those nominated by a separate applicant.

Demographic and Eligibility Information

1. Please check one:

• I am self-nominating myself or my organization.

• I am nominating an individual other than myself, or an organization/community coalition that I am not currently affiliated with.

2. This nomination is for an:

• Individual

• Organization/Community Coalition

3. Name of Applicant : ____________________________

4. Name of Applicant’s Organization. Please enter “N/A” if not-applicable. ________________________________________________________________________

5. Applicant’s E-mail: _______________________________________________

6. Name of nominee (if different from applicant): _______________________________________________

7. Nominee’s website (if nominee is an organization/coalition): ________________________________________________

8. Nominee’s affiliation with REACH (select all that apply):

1. Currently funded recipient

2. Previously funded recipient

3. Technical assistance provider to current or former REACH Recipients

4. Partner organization or coalition that has collaborated with current or former REACH recipient

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0390. The time required to complete this information collection is estimated to average 90 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

9. Select the racial or ethnic group(s) that the nominee worked with to address disparities.

   1. African American people

   2. American Indian/Alaska Native people

   3. Hispanic people

   4. Asian American people

   5. Native Hawaiian/Other Pacific Islander people.

Award Information: Please answer the following questions. Responses to each question should be no more than 300 words.

1. Describe the specific challenge(s) that the nominee addressed and the strategies that the nominee used to address the challenge(s).

2. What preventable risk factors that are associated with chronic diseases (hypertension, heart disease, type 2 diabetes, and/or obesity) did the nominee address? Select all that apply.

   1. Tobacco use

   2. Inadequate access to clinical services

   3. Poor nutrition

   4. Physical inactivity

3. How does the nominee’s work align with the National Center for Chronic Disease Prevention and Health Promotion’s (NCCDPHP’s) goals of by addressing social determinants of health (SDOH). Examples of SDOH include, but are not limited to: built environment, community-clinical linkages, food and nutrition security, social connectedness, and tobacco-free policies.

4. How does the nominee’s work contribute to developing, implementing, and/or evaluating solutions that are

• Culturally-tailored?

• Evidence-based or practice-based?

• Designed to reduce health inequities for populations/groups disproportionately affected by chronic disease or related risk behaviors?

5. How does the nominee’s work actively and effectively engage members of the community and partners across different sectors, such as, but not limited to transportation, healthcare, agriculture, emergency food systems, faith-based organizations.

6. Describe the impact of the nominee’s work on addressing preventable risk factors in populations/groups disproportionately affected by chronic diseases.

Supplementary Materials

Applicants can also submit supplemental materials that demonstrate the nominee’s work and/or impact publications not to exceed 10 total pages. Examples of supplementary materials include: PDF of online content, and other forms of written material Please highlight content you would like to be reviewed. Will you be submitting additional materials to be considered?

• Yes

• No

If yes, please provide the title of the material(s) and a brief description.

Agreement to Participate:

• Please check the box at the end of this section indicating that you, as the applicant, agree to the following requirements. The applicant refers to each individual or organization/community coalition who submits and application or nomination. The nominee refers to each individual or organization/community coalition who is nominated, including both self-nominated nominees and those nominated by a separate applicant.

  • By participating, the applicant represents, warrants, and agrees that the entry contains accurate information.

  • Applicants and nominees must agree to recognition if selected as an awardee, and agree to participate in an interview to develop a success story that describes the intervention(s) that promoted health equity.

    • The awardee may be recognized on CDC’s Division of Nutrition, Physical Activity, and Obesity website or the CDC website generally.

    • Applicants and nominees who are not selected for the award may be asked for permission for CDC to share information about successful interventions that promoted health equity on CDC's Division of Nutrition, Physical Activity, and Obesity website, or the CDC website, and attributed to the applicant or nominee. CDC will obtain approval from the applicant and/or nominee before sharing information about the applicant/nominee publicly.

• By participating

  • Individuals and organizations agree to assume any and all risks related to participating in the award process. Individuals or organizations also agree to waive claims against the federal government and its related entities, except in the case of willful misconduct, when participating in the award process, including claims for injury, death, damage, or loss of property, money, or profits, and including those risks caused by negligence or other causes

• I agree to the terms above. Date:_____________________

Thank you for Participating!