0920-0909 DPRP Application Form

Apply for CDC Recognition

Diabetes Prevention Recognition Program Application

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).

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

Before You Begin

Please acknowledge the following before submitting your application*

I have read and understand the DPRP Standards and Operating Procedures.

My organization has taken the Organizational Capacity Assessment and is ready to apply for CDC recognition.

Our organization staff has read and understands the Health Equity Guiding Principles for Inclusive Communication (Health Equity Guiding Principles for Inclusive Communication | Gateway to Health Communication | CDC). We will apply these principles in our communications to the best of our ability.

NOTE: If you would like to review your Capacity Assessment results with a member of the Technical Assistance Team, please submit that request by clicking on “Contact Us” on the National DPP Customer Service Center website.

General Information

1. Type of Application *

☐ Initial

☐ Re-Apply

2. Previous OrgCode Assigned (Enter only if Re-Apply is selected)

3. Organization Name*

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

4. 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*

(Drop down box of states, territories, and freely associated states)

Zip Code*

+4

Please verify address to continue

Verify Address *Address Tips

5. Organization Web Address or URL (Optional)

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

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.

6. Organization Phone Number*

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

Phone Area Code - First 3 - Last 4 Ext:

7. Organization Level Email (Optional)

This is the email address that participants, payers, and others may contact to obtain information about your program. Upon approval of your application, this will be published in the DPRP registry and on the National DPP Locator.

Email:

8. 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

Tribes, Tribal-serving Organizations, Urban Indian Organizations, Indian Health Service Sites

Cooperative Extension Sites

Worksites/Employee Wellness Programs/Private Businesses

Senior/Aging/Elder Centers

Health Plans/Insurers

Faith-Based Organizations/Churches

☐ My organization is also an ADA-recognized DSMES organization.

☐ My organization is also an ADCES-accredited DSMES organization.

Type of Delivery

9. Delivery Mode (check only one)

In-person* (if chosen, display basic application and SVI blurb and link)

Distance Learning (live) (if chosen, display distance learning questions)

In-person with a Distance Learning Component* (if chosen, display distance learning questions)

Online (non-live) (if chosen, display online questions)

Combination with an Online Component (if chosen, display combination non-live delivery questions)

*Organizations delivering or wanting to deliver the MDPP may only deliver using these modes.

Questions Specific to In Person

In-person is defined as “a yearlong National DPP LCP delivered 100% in-person for all participants by trained Lifestyle Coaches. Participants are physically present in a classroom or classroom-like setting.”

Your organization will be considered for immediate advancement to Preliminary recognition if you are serving a population that resides in a county classified as having “High” vulnerability according to the CDC/ATSDR Social Vulnerability Index (SVI). Social vulnerability refers to the potential negative effects on communities caused by external stresses on human health. Such stresses include natural or human-caused disasters, or disease outbreaks. Reducing social vulnerability can decrease both human suffering and economic loss.

To determine the SVI of the community/communities you’re serving, go to the website and enter the zip code or county. Themes in SVI include socioeconomic status, household characteristics, racial and ethnic minority status, and housing type and transportation.

☐ My organization is interested in moving immediately into Preliminary recognition by enrolling participants who reside in a county classified as having High Vulnerability by the CDC/ATSDR Social Vulnerability Index.

☐ I agree to deliver sessions in accordance with section I. Guidelines for Session Delivery of the DPRP Standards, particularly those points that pertain specifically to in-person session delivery.

Questions Specific to Distance Learning (live)

Distance Learning delivery is defined as “a yearlong National DPP lifestyle change program delivered 100% by trained Lifestyle Coaches via remote classroom or telehealth. The Lifestyle Coach provides live (synchronous) delivery of session content in one location and participants call-in or video-conference from another location.”

Are you open to participants in every U.S. state, territory, or freely associated states?

☐ Yes

☐ No (if no, populate with drop down of states and territories)

☐ I agree to deliver sessions in accordance with section I. Guidelines for Session Delivery of the DPRP Standards, particularly those points that pertain specifically to in-person session delivery.

Questions Specific to In-person with a Distance Learning Component

A yearlong National DPP LCP delivered in-person by trained Lifestyle Coaches, where participants have the option of attending sessions via remote classroom or telehealth (the Lifestyle Coach provides live delivery of session content in one location and participants call-in or video-conference from another location. Examples of an acceptable delivery model for in-person with a distance learning component include:

1. A combination of in-person and distance learning during the Core and Core Maintenance phases.

2. Some participants within a cohort using in-person delivery mode and some participants in a cohort using distance learning delivery mode.

3. Participants choose from session to session which mode (in-person or distance learning) they wish to use.

Your organization will be considered for immediate advancement to Preliminary recognition if you are serving a population that resides in a county classified as having “High” vulnerability according to the CDC/ATSDR Social Vulnerability Index (SVI). Social vulnerability refers to the potential negative effects on communities caused by external stresses on human health. Such stresses include natural or human-caused disasters, or disease outbreaks. Reducing social vulnerability can decrease both human suffering and economic loss.

To determine the SVI of the community/communities you’re serving, go to the website and enter the zip code or county. Themes in SVI include socioeconomic status, household characteristics, racial and ethnic minority status, and housing type and transportation.

☐ My organization is interested in moving immediately into Preliminary recognition by enrolling participants who reside in a county classified as having High Vulnerability by the CDC/ATSDR Social Vulnerability Index.

☐ I agree to deliver sessions in accordance with section I. Guidelines for Session Delivery of the DPRP Standards, particularly those points that pertain specifically to in-person session delivery.

Questions Specific to Online

Online delivery is defined as “a yearlong National DPP lifestyle change program delivered online for all participants. One hundred percent of the program is experienced through the Internet via phone, tablet, or laptop, in an asynchronous classroom where participants are experiencing the content on their own time without a live Lifestyle Coach teaching the content. However, live Lifestyle Coach interaction should be provided to each participant no less than once per week during the first six months and once per month during the second six months. E-mails and text messages can count toward the requirement for live coach interaction as long as there is bi-directional communication between coach and participant. Chat bots and Artificial Intelligence (AI) forums do not count as live Lifestyle Coach interaction.”

Are you open to participants in every U.S. state, territory, or freely associated states?

☐ Yes

☐ No (if no, populate with drop down of states and territories)

☐ I agree to deliver sessions in accordance with section I. Guidelines for Session Delivery of the DPRP Standards, particularly those points that pertain specifically to online session delivery.

Questions Specific to Combination with an Online Component

Combination with an Online Component Delivery is defined as “a yearlong National DPP LCP delivered as a combination of online (non-live) with in-person and/or distance learning (defined as above). Delivering any number of live sessions under this mode will not allow the organization to be considered a live delivery program. All data collected from each mode are consolidated. Examples of an acceptable delivery model include:

• The use of one modality such as in-person and/or distance learning in the Core phase of the program and online in the Core Maintenance phase.

• A consistent delivery approach using two or three modalities for each participant in a rotating manner (e.g., one session in-person and the next session online or 5 sessions online and the next 5 sessions via distance learning).

• Entire cohorts conducted using different delivery modes (one cohort in-person and/or via distance learning and another cohort online).

• Some participants within a cohort using one delivery mode and some participants within the same cohort using the other.

• Participants choose from session to session which mode they wish to use.

Which modes in addition to online will you be using?

☐In-person

☐Distance Learning

(Questions associated with modes checked)

Are you open to participants in every U.S. state, territory, or freely associated states?

☐ Yes

☐ No (if no, populate with drop down of states and territories)

Program Coordinator

1. 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.

Drop down menu options for Title:

Behavioral Health Specialist

Community Health Worker

Coordinator/Manager/Supervisor/Director

Diabetes Educator

Government Personnel

Health Educator – non-Diabetes

Medical Doctor

Nurse

Nutritionist

Other Healthcare Professional

Pharmacist

Registered Dietitian/ Registered Dietitian Nutritionist

Wellness or Fitness Instructor/ Professional

Other <text box to specify>

2. 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 )

3. 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

Drop down menu options for Title:

Behavioral Health Specialist

Community Health Worker

Coordinator/Manager/Supervisor/Director

Diabetes Educator

Government Personnel

Health Educator – non-Diabetes

Medical Doctor

Nurse

Nutritionist

Other Healthcare Professional

Pharmacist

Registered Dietitian/ Registered Dietitian Nutritionist

Wellness or Fitness Instructor/ Professional

Other <text box to specify>

4. 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 )

5. 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.

6. 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

7. Class Type (check all that apply) *

Public

Employees

Members

Other (write in target audience served such as American Indians/Alaskan Natives, patients, clients, etc.

8. 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 National DPP Customer Service Center website

(Drop down menu)

Association of Diabetes Care & Education Specialists (ADCES)

Black Women’s Health Imperative (BWHI)

Diabetes Training and Technical Assistance Center (DTTAC)

J Moss Foundation

Magnolia Medical Training Group

ProVention Health Foundation

Solera Health

SparkPro

State of Wellness

Telligen

CS-3 Temple University

Touro University California Training

Virginia Center for Diabetes Prevention and Education (VCDPE)

A private organization with national reach

(Drop down menu)

YMCA of the USA

Other

A virtual organization with national reach

(Drop down menu)

LARK

HabitNu

Omada Health

Other

A Master Trainer (MT) who completed an MT program

Name of training provider*

Name of training entity

(Drop down menu)

Association of Diabetes Care & Education Specialists (ADCES)

Black Women’s Health Imperative (BWHI)

Diabetes Training and Technical Assistance Center (DTTAC)

J Moss Foundation

Magnolia Medical Training Group

ProVention Health Foundation

Solera Health

SparkPro

State of Wellness

Telligen

CS-3 Temple University

Touro University California Training

Virginia Center for Diabetes Prevention and Education (VCDPE)

9. Curriculum. *

If you select Other Curriculum, you must submit your curriculum files.

2016 PreventT2 - English

2016 PreventT2 – Spanish

2016 PreventT2 – English and Spanish

2021 PreventT2 - English

2021 PreventT2 – Spanish

2021 PreventT2 – English and Spanish

Native Lifestyle Balance-Preventing Diabetes in American Indian Communities

Other Curriculum

Do modules include additional content outside the CDC-approved curriculum (i.e., videos, webinars, resources, recipes, articles)?*

Yes

No

Do you have a projected start date?

Yes (if yes, a calendar will pop up)

No

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.)

Name of Authorized Representative*

Title of Authorized Representative*

Organization Name*

Today's 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.