The National Cardiovascular Health Program CDC-RFA-DP-23-0004

Centers for Disease Control and Prevention
NATIONAL CENTER FOR CHRONIC DISEASE PREVENTION AND HEALTH
PROMOTION
The National Cardiovascular Health Program
CDC-RFA-DP-23-0004
04/25/2023

Table of Contents
A. Funding Opportunity Description ...............................................................................................3
B. Award Information ....................................................................................................................30
C. Eligibility Information ..............................................................................................................31
D. Application and Submission Information .................................................................................33
E. Review and Selection Process ...................................................................................................44
F. Award Administration Information ...........................................................................................49
G. Agency Contacts .......................................................................................................................56
H. Other Information .....................................................................................................................57
I. Glossary ......................................................................................................................................58

Part I. Overview
Applicants must go to the synopsis page of this announcement at www.grants.gov and click on
the "Subscribe" button link to ensure they receive notifications of any changes to CDC-RFA-DP23-0004. Applicants also must provide an e-mail address to www.grants.gov to receive
notifications of changes.
A. Federal Agency Name:
Centers for Disease Control and Prevention (CDC) / Agency for Toxic Substances and Disease
Registry (ATSDR)
B. Notice of Funding Opportunity (NOFO) Title:
The National Cardiovascular Health Program
C. Announcement Type: New - Type 1:
This announcement is only for non-research activities supported by CDC. If research is
proposed, the application will not be considered. For this purpose, research is defined
at https://www.gpo.gov/fdsys/pkg/CFR-2007-title42-vol1/pdf/CFR-2007-title42-vol1-sec522.pdf. Guidance on how CDC interprets the definition of research in the context of public health
can be found at https://www.hhs.gov/ohrp/regulations-and-policy/regulations/45-cfr46/index.html (See section 45 CFR 46.102(d)).
D. Agency Notice of Funding Opportunity Number:
CDC-RFA-DP-23-0004
E. Assistance Listings Number:
93.426
Page 1 of 63

F. Dates:
1. Due Date for Letter of Intent (LOI):
2. Due Date for Applications:
04/25/2023
11:59 p.m. U.S. Eastern Standard Time, at www.grants.gov.
3. Due Date for Informational Conference Call:
The National Cardiovascular Health Program
Applicant Informational Webinar
Thursday, March 9, 2023
2:00pm - 3:00pm ET

Click the link below to join the webinar:
https://cdc.zoomgov.com/j/1604944328?pwd=VXJNUmZ6TFE4VE0wcVRUVVV3b21HUT09
Or join by phone:
US: +1 669 254 5252 or +1 646 828 7666 or +1 646 964 1167 or +1 551 285 1373 or +1 669
216 1590 or +1 415 449 4000
Webinar ID: 160 494 4328
Passcode: 51291371

Additional information about this and other DHDSP funding opportunities may be found at:
https://www.cdc.gov/dhdsp/funding-opps/index.htm
Questions about this NOFO may be submitted via email: [email protected]
Responses will be posted to the NOFO informational website.

G. Executive Summary:
1. Summary Paragraph
This NOFO supports state investments in implementing and evaluating evidence-based and
evidence-informed strategies to prevent and manage cardiovascular disease (CVD) in each state
and the District of Columbia.
The populations of focus are those impacted by the high prevalence of CVD, exacerbated by
health inequities and disparities, social determinants, such as low incomes, poor health care, and
unfair opportunity structures. Specific emphasis is placed on the prevention and control of
hypertension and high cholesterol.

Page 2 of 63

An applicant must demonstrate the capacity to achieve outcomes that reduce hypertension and
high blood cholesterol in alignment with the broad strategies indicated. The applicant must
accomplish these outcomes by aligning with and joining an existing, or creating a new, learning
collaborative (LC). LCs will support health agencies in various jurisdictions to facilitate
communication and the exchange of ideas and leverage technical and financial resources to
support programs to improve cardiovascular health outcomes for all persons but specifically
focus on those with or at highest risk of poor cardiovascular health outcomes. The LCs should
directly intervene on a clinical or community basis to address the social determinants of health.
This new funding opportunity builds on the outcomes achieved via CDC-RFA-DP18-1815 and
CDC-RFA-DP18-1817 and provides a structured environment for states to work more
deliberately for the advancement of health equity.
a. Eligible Applicants:
Open Competition
b. Funding Instrument Type:
CA (Cooperative Agreement)
c. Approximate Number of Awards
51
d. Total Period of Performance Funding:
$275,000,000
e. Average One Year Award Amount:
$1,000,000
f. Total Period of Performance Length:
5 year(s)
g. Estimated Award Date:
May 30, 2023
h. Cost Sharing and / or Matching Requirements:
No
Part II. Full Text
A. Funding Opportunity Description
1. Background
a. Overview
Extensive scientific evidence links nonmedical factors, including systemic racism and the lack of
economic opportunities, with poor health outcomes and increased mortality rates, all of which
are preventable. Factors such as poverty, inadequate housing, poor health care, and other
debilitating social conditions, commonly referred to as social determinants of health, contribute
to long-standing disparities and health inequities.
These social conditions contribute to the increased prevalence of cardiovascular disease (CVD)
in the US population. CVD is the leading cause of death in the US; stroke is the 5th leading
cause. In 2020, about 1 in 5 adults who died from CVD were younger than 65 years old. It is
estimated that 1 in 9 health care dollars are spent on CVD.
Page 3 of 63

CVD mortality rates declined for several decades due to both clinical and public health
interventions, but recently declining death rates from both heart disease and stroke have stalled.
One reason is that hypertension, the primary risk factor for CVD, is very common (1 in 2 US
adults has hypertension) but control is not. Only 1 in 4 adults with hypertension (26.1%) has it
under control.
Gains have been made in treating high cholesterol, another primary risk factor for CVD. Overall,
the age-adjusted prevalence of high cholesterol decreased from 21% to 10% from 1988–1994 to
2017–2018. This improvement is due in part to individuals’ healthy behaviors such as eating a
healthy diet, losing weight, being physically active, and medication adherence, along with
clinical contributions from appropriate prescribing and intensification of medication. Additional
public health and health system interventions aimed at preventing, detecting, and controlling
elevated cholesterol and blood pressure can help to further decrease CVD mortality.
This NOFO aims to implement and evaluate evidence-based strategies contributing to the
prevention and management of CVD in populations disproportionately at risk. Given the
importance of health equity, this new NOFO also addresses social and economic factors to help
communities and health systems respond to social determinants present in their communities to
offer those at risk of or burdened with CVD the best health outcomes possible.

b. Statutory Authorities
Sec 317(a) of the Public Health Service Act [42 USC 247b]
Title IV Section 4002 of the Affordable Care Act, Prevention and Public Health Fund [42 USC
300u-11]
c. Healthy People 2030
Healthy People 2030 objectives related to Heart Disease and Stroke:
https://health.gov/healthypeople/objectives-and-data/browse-objectives/heart-disease-andstroke

HDS-01: Improve cardiovascular health in adults
HDS-02: Reduce coronary heart disease deaths
HDS-03: Reduce stroke deaths
HDS-04: Reduce the proportion of adults with high blood pressure
HDS-05: Increase control of high blood pressure in adults
HDS-06: Reduce cholesterol in adults
HDS-07: Increase cholesterol treatment in adults
HDS-D07: Increase the proportion of adults whose risk for atherosclerotic cardiovascular disease
was assessed
Page 4 of 63

d. Other National Public Health Priorities and Strategies
 CMS Framework for Health Equity 2022-2032:
https://www.cms.gov/files/document/cms-framework-health-equity.pdf


HHS Equity Action Plan: https://www.hhs.gov/sites/default/files/hhs-equity-actionplan.pdf



HRSA Strategic Plan FY23: https://www.hrsa.gov/about/strategic-plan



Million Hearts® 2027: https://millionhearts.hhs.gov/index.html



The Guide to Community Preventive Services:
https://www.thecommunityguide.org/topics/heart-disease-stroke-prevention.html



The Surgeon General’s Call to Action to Control Hypertension:
https://www.hhs.gov/sites/default/files/call-to-action-to-control-hypertension.pdf

e. Relevant Work
This NOFO builds on the accomplishments and outcomes achieved via Improving the Health of
Americans Through Prevention and Management of Diabetes and Heart Disease and Stroke
(CDC-RFA-DP18-1815) (https://www.cdc.gov/chronicdisease/about/foa/1815/index.htm) and
Diabetes and Heart Disease & Stroke Prevent Programs-Innovative State and Local Public
Health Strategies to Prevent and Manage Diabetes and Heart Disease and Stroke (CDC-RFADP18-1817) (https://www.cdc.gov/chronicdisease/programs-impact/supported/index.htm).
2. CDC Project Description
a. Approach
Bold indicates period of performance outcome.

Required Strategies

Short-Term Outcomes

Strategy 1. Track and Monitor Clinical and Social
Services and Support Needs Measures Shown to
Improve Health and Wellness, Health Care
Quality, and Identify Patients at Highest Risk of
Cardiovascular Disease (CVD) with a Focus on
Hypertension and High Cholesterol.

Intermediate Term
Outcomes

Long-Term
Outcomes

Improved blood pressure
control among populations Improved
within partner health care cardiovascular
and community settings. health

Reduced disparities in
blood pressure control
1A. Advance the adoption Increased use of
among populations within
and use of electronic
EHRs or HIT to
health records (EHR) or report, monitor, and partner health care and
community settings.
health information
track clinical and
technology (HIT), to
social services and
identify, track, and
support needs data to
monitor measures for
improve detection of Increased utilization of
clinical and social services health care disparities social services and support

Reduced
disparities in
cardiovascular
health

Page 5 of 63

and support needs to
address health care
disparities and health
outcomes for patients
at highest risk of
cardiovascular disease
(CVD) with a focus on
hypertension and high
cholesterol.

and the identification, among populations at
management, and
highest risk of CVD, with a
treatment of patients focus on hypertension and
at highest risk of
high cholesterol.
CVD, with a focus on
hypertension and high
cholesterol.

1B. Promote the use of
Increased use of
standardized processes or standardized
tools to identify the social processes or tools to
services and support needs identify, assess, track,
of patient populations at and address the social
highest risk of CVD, with services and support
a focus on hypertension needs of patient
and high cholesterol, and populations at highest
monitor and assess the
risk of CVD.
referral and utilization of
those services, such as
food assistance,
transportation, housing,
childcare, etc.
Strategy 2: Implement Team-Based Care to
Prevent and Reduce CVD Risk with a Focus on
Hypertension and High Cholesterol Prevention,
Detection, Control, and Management through the
Mitigation of Social Support Barriers to Improve
Outcomes.
2A. Advance the use of
Increased use of
health information systems EHRs or HIT to
that support team-based support
care to monitor population communication and
health with a focus on
coordination among
health disparities,
care team members to
hypertension, and high
monitor and address
cholesterol.
patients’ hypertension
and high cholesterol.
2B. Assemble or create
multidisciplinary teams
(e.g., nurses, nurse
practitioners, pharmacists,
nutritionists, physical
therapists, social workers,
and community-based

Increased use of
multidisciplinary care
teams adhering to
evidence-based
guidelines to address
patients' social
services and support
Page 6 of 63

workers) to identify
patients' social services
and support needs and to
improve the management
and treatment of
hypertension and high
cholesterol.

needs and improve
the management and
treatment of
hypertension and high
cholesterol.

2C. Build and manage a Increased
coordinated network of
multidisciplinary
multidisciplinary
partnerships that
partnerships that address address identified
identified barriers to social barriers to social
services and support needs services and support
(e.g., childcare,
needs
transportation, language within populations
translation, food
at highest risk of
assistance, and housing) CVD.
within populations at
highest risk of CVD.
Strategy 3: Link Community Resources and
Clinical Services that Support Bidirectional
Referrals, Self-Management, and Lifestyle Change
to Address Social Determinants that Put the
Priority Populations at Increased Risk for
Cardiovascular Disease with a Focus on
Hypertension and High Cholesterol.
3A. Create and enhance
community-clinical links
to identify SDOH (e.g.,
inferior housing, lack of
transportation, inadequate
access to care, and limited
community resources) and
respond to social services
and support needs of
populations at highest risk
of CVD with a focus on
hypertension and high
cholesterol.

Increased community
clinical links to
identify and respond
to social services and
support needs
of populations at
highest risk of CVD
with a focus on
hypertension and high
cholesterol.

3B. Identify and deploy
dedicated CHWs (or their
equivalents) to provide a
continuum of care and
services which extend the

Increased engagement
of CHWs (or their
equivalents) to
provide a continuum
of care extending
Page 7 of 63

benefits of clinical
clinical interventions
interventions and address and addressing social
social services and support services and support
needs leading to optimal needs.
health outcomes.
3C. Promote use of selfmeasured blood pressure
monitoring (SMBP) with
clinical support
within populations
at highest risk of
hypertension.

Increased use of SMBP
with clinical support
within populations at
highest risk of
hypertension.

i. Purpose
This NOFO supports state investments in implementing and evaluating evidence-based and
evidence-informed strategies to prevent and manage CVD in select populations in each state and
the District of Columbia. This must be achieved by joining or creating an LC and demonstrating
capacity to reduce hypertension and high cholesterol in alignment with specified strategies. The
persons of focus are impacted by a high prevalence of CVD, exacerbated by health inequities and
disparities, social determinants, such as inadequate health care, education, poverty, and unfair
opportunity structures.
ii. Outcomes
Short-term outcomes by strategy
Strategy 1:




Increased use of EHRs or HIT to report, monitor, and track clinical and social services
and support needs data to improve detection of health care disparities and the
identification, management, and treatment of patients at highest risk of cardiovascular
disease, with a focus on hypertension and high cholesterol.
Increased use of standardized processes or tools to identify, assess, track, and address the
social services and support needs of patient populations at highest risk of CVD.

Strategy 2:




Increased use of EHRs or HIT to support communication and coordination among care
team members to monitor and address patients’ hypertension and high cholesterol.
Increased use of multidisciplinary care teams adhering to evidence-based guidelines to
address patients' social services and support needs and improve the management and
treatment of hypertension and high cholesterol.
Increased multidisciplinary partnerships that address identified barriers to social services
and support needs within populations at highest risk of CVD.
Page 8 of 63

Strategy 3:




Increased community clinical links to identify and respond to social services and support
needs of populations at highest risk of CVD with a focus on hypertension and high
cholesterol.
Increased engagement of CHWs (or their equivalents) to provide a continuum of care
extending clinical interventions and addressing social services and support needs.
Increased use of SMBP with clinical support within populations at highest risk of
hypertension.

Intermediate outcomes include:




Improved blood pressure control among populations within partner health care and
community settings.
Reduced disparities in hypertension control among populations within partner health care
and community settings.
Increased utilization of social services and support among populations at highest risk of
CVD, with a focus on hypertension and high cholesterol.

iii. Strategies and Activities
Applicants must address all strategies.
Strategy 1: Track and Monitor Clinical and Social Services and Support Needs Measures Shown
to Improve Health and Wellness, Health Care Quality, and Identify Patients at the Highest Risk
of Cardiovascular Disease (CVD) with a Focus on Hypertension and High Cholesterol.




1A: Advance the adoption and use of electronic health records (EHR) or health
information technology (HIT), to identify, track, and monitor measures for clinical and
social services and support needs to address health care disparities and health outcomes
for adults at highest risk of cardiovascular disease (CVD) with a focus on hypertension
and high cholesterol.
1B: Promote the use of standardized processes or tools to identify the social services and
support needs of patient populations at highest risk of CVD, with a focus on hypertension
and high cholesterol, and monitor and assess the referral and utilization of those services,
such as food assistance, transportation, housing, childcare, etc.

Strategy 2: Implement Team-Based Care to Prevent and Reduce CVD Risk with a Focus on
Hypertension and High Cholesterol Prevention, Detection, Control, and Management Through
the Mitigation of Social Support Barriers to Improve Outcomes.



2A: Advance the use of health information systems that support team-based care to
monitor population health with a focus on health disparities, hypertension, and high
cholesterol.
2B: Assemble or create multidisciplinary teams (e.g., nurses, nurse practitioners,
pharmacists, nutritionists, physical therapists, social workers, and community-based
workers) to identify patients' social services and support needs and to improve the
management and treatment of hypertension and high cholesterol.
Page 9 of 63



2C: Build and manage a coordinated network of multidisciplinary partnerships that
address identified barriers to social services and support needs (e.g., childcare,
transportation, language translation, food assistance, and housing) within populations at
highest risk of CVD.

Strategy 3: Link Community Resources and Clinical Services That Support Bidirectional
Referrals, Self-Management, and Lifestyle Change to Address Social Determinants That Put the
Priority Populations at Increased Risk of Cardiovascular Disease with a Focus on Hypertension
and High Cholesterol.





3A: Create and enhance community-clinical links to identify SDOH (e.g., inferior
housing, lack of transportation, inadequate access to care, and limited community
resources) and respond to the social services and support needs of populations at highest
risk of CVD with a focus on hypertension and high cholesterol.
3B: Identify and deploy dedicated CHWs (or their equivalents) to provide a continuum of
care and services which extend the benefits of clinical interventions and address social
services and support needs leading to optimal health outcomes.
3C: Promote use of self-measured blood pressure monitoring (SMBP) with clinical
support within populations at highest risk of hypertension.

Previous CDC-supported initiatives provided opportunities for a limited number of states already
receiving direct funding from CDC to support their core heart disease and stroke prevention
programs to participate in the Heart Disease and Stroke Learning Collaboratives (LC) which
were also funded by CDC. For the purposes of this NOFO, an LC is defined as a group of public
health entities, health systems, health care providers, and community leaders and their partners
with experience working to address and implement evidence-based or evidence-informed
practices for CVD prevention, detection, control, and management among approved priority
populations of focus. The LC is expected to facilitate communication and the exchange of ideas
between health systems, community health organizations, and public health entities. The
applicant must demonstrate a history of collaborating to achieve sustainable change and
improvement in the areas outlined in the NOFO. They will leverage technical and financial
resources to support programs to improve cardiovascular health outcomes for all persons but
specifically focus on those with or at the highest risk of poorer health outcomes.
The LC may be an alliance of public health entities, housing, commerce, and transportation
agencies, health systems, health care providers, clinical quality improvement organizations,
health information technology experts, public and private payers, pharmacists, mental and
behavioral health professionals, community-based health care professionals, community
organizations, safety net providers, health departments, tribal organizations and others. These
partners may also directly intervene on a clinical or community basis to address the social
determinants of health (SDOH).
The goals of a heart disease and stroke learning collaborative are:


Prioritizing populations and communities with the highest prevalence of CVD, with a
focus on advancing health equity for individuals with hypertension and high cholesterol.

Page 10 of 63





Serving populations and communities affected disproportionately by CVD, specifically
hypertension, high cholesterol, or stroke, due to unfair opportunity structures and social
determinants, such as limited access to care, inadequate or poor quality of care, or
economic instability.
Achieving optimal health outcomes for priority populations through culturally informed
program services that use focused strategies to advance universal health equity goals that
are mindful of the social determinants.

This new funding opportunity will build on the accomplishments and outcomes achieved in the
healthcare system and community-clinical link domains of CDC-RFA-DP18-1815 and CDCRFA-DP18-1817 and provide a structured environment for states to work more deliberately on
systems change and the advancement of health equity. It will allow state health departments
(SHD) to collaborate with a heart disease and stroke LC or similar entity. If one does not exist,
SHDs will be able to create new LCs. The LC must adhere to and have the following
characteristics:













Recipients must ensure there is no duplication in the establishment of LCs in the same
local or regional jurisdictions identified under CDC-RFA-DP-23-0005: The Innovative
Cardiovascular Health Program.
Recipients must be able to document, explain, and report on the effects of efforts to
address the impact of racism and other social injustices on cardiovascular health
outcomes, specifically hypertension, high cholesterol, and stroke.
Post-award, in response to the Technical Review, recipients will be expected to develop
detailed action plans that list key partners and complement the work plan, the first of
which must be in place within the first 180 days.
Within the first three (3) months, use Geographic Information System (GIS) mapping
technology to identify census areas with priority populations at the highest risk for
cardiovascular health conditions. This includes identifying thresholds to determine the
number of persons the state health departments (SHDs) must reach to achieve
predetermined health equity goals.
Newly established LCs and partnerships with existing LCs must ensure at least 51% of
participating collaborators and partners represent approved priority populations of focus.
A dedicated staff person must be identified, as evidenced by explicit inclusion in the
work plan and budget, who will focus on health inequities and build relationships at the
designated levels to decrease health care disparities and advance health equity. This
person can be the learning collaborative lead.
Design and implement strategies using EHR/HIT to detect and mitigate health care
disparities and utilize Quality Improvement techniques, resulting in optimal health
outcomes.
Create and enhance community-clinical links. These partnerships should reflect an
interdisciplinary team that resembles the identified communities and populations and can
respond to SDOH, and social services and support needs. Referrals must include agencies
in the community that serve the priority population and provide safety net services.
LC partnerships must strengthen efforts to expand care teams to include health care
providers, community health workers, social workers, patient navigators, pharmacists,
Page 11 of 63



and other members of the care team in community settings outside of health care facilities
to enhance follow-up, communication, and coordination among identified communities
and populations.
Members of the LC must examine existing policies that are barriers to optimal health
outcomes and engage in mitigation strategies aimed at system-level changes that reduce
health and health care disparities, and improve community conditions.

During the Period of Performance, the Learning Collaborative is also charged with:



Increasing the percentage of patients 18–85 years of age who have had a hypertension
diagnosis and among those diagnosed, blood pressure was adequately controlled during
the measurement year.
Examine and implement models for collaboration between public health, health care, and
community partners.

1. Collaborations
a. With other CDC projects and CDC-funded organizations:
An applicant should describe the ability to establish strategic partnerships with other CDCfunded programs in and outside the state health departments, tribes and tribal organizations and
community-based organizations. This will allow for more efficient use of existing resources.
These include but are not limited to other CDC-funded heart disease and stroke programs such as
WISEWOMAN, The Innovative Cardiovascular Health Program, Paul Coverdell National Acute
Stroke Program, Good Health and Wellness in Indian Country (GHWIC), Community Health
Workers for COVID Response and Resilient Communities, and the Million Hearts® initiative.
It is important that an applicant identify and leverage opportunities and partnerships that will
help address unfair opportunity structures and the social determinants of health. This will
enhance the recipient’s work with other state health department programs that address related
chronic diseases or their underlying risk factors.
An applicant is encouraged to engage and garner support from both internal and external partners
with varied expertise. Applicants must include MOUs or MOAs, as appropriate, name the file
“MOUs/MOAs”, and upload it as a PDF file at www.grants.gov.
b. With organizations not funded by CDC:
An applicant should describe its history of establishing or partnering with multi-sectoral learning
collaboratives (LC) and collaborating with organizations with a history of working with
populations impacted by the high prevalence of CVD, with specific emphasis on hypertension
and high cholesterol exacerbated by health inequities and disparities, social determinants, such as
low incomes, poor health care, and unfair opportunity structures. The applicant should describe
proposed collaborations relevant to strategies in the NOFO. These partners may include
employers, hospitals, non-profit agencies, other federal, state, or local government agencies,
tribes or tribal organizations, professional associations (e.g., a state medical society, medical
specialty associations, etc.), quality improvement organizations, housing, commerce, or
transportation agencies, health systems, health care providers, health information technology
Page 12 of 63

experts, public and private payers, pharmacists, mental and behavioral health professionals,
community-based health care professionals, community organizations, safety net providers, and
others. It is critical to demonstrate meaningful collaboration with state level Offices of Health
Equity, Offices of Minority Health or their equivalent. If an agency does not have this resource,
efforts should be made to locate an organization at the state or regional level that possesses this
expertise, including expertise in health equity.
The applicant should include letters of support, memoranda of understanding (MOU), or
memoranda of agreement (MOA) with a firm commitment from providers and partners that
outline the relationship, needs, and resources to be provided. The applicant should submit letters
of support from organizations and providers that will have a role in helping to achieve specific
NOFO activities and outcomes. Letters and Memoranda must be dated within 45 days of the
application. The files should be named “MOUs/MOAs.Applicant Name" and uploaded as a PDF
file at www.grants.gov.

2. Target Populations
Applicants must identify criteria for selecting their priority populations based on disease and risk
factor burden data and combined potential to impact large numbers of adults across the state.
Priority populations should include those affected disproportionately by hypertension and high
cholesterol due to socioeconomic or other factors, including inadequate access to care, poor
quality of care, or low income. Emphasis should be placed on achieving maximum reach and
impact across populations who can benefit from the strategies included in this NOFO.
a. Health Disparities
This NOFO will address the challenges and health inequities in priority populations
disproportionally impacted by cardiovascular disease. These efforts will help determine the
public health impact of programs intended to improve specific risks, conditions, and barriers
experienced by populations living with high levels of disease burden for hypertension and high
cholesterol.
Racial and ethnic minority groups across the US experience a disproportionate impact of CVD.
Higher risk of CVD, including hypertension and high cholesterol, is the result of unfair
opportunity structures and social determinants that reflect low socioeconomic factors, such as
living in underfunded urban, rural, and frontier communities, being uninsured or underinsured,
having limited access to routine medical care, or other related factors.
iv. Funding Strategy
The table below provides guidance related to the maximum amount of funding available by state
for this program. This funding is based on a formula that includes factors for base funding,
population, poverty, and disease burden.
State

Total Dollar Amount to Request

Alabama

$1,147,666

Alaska

$877,496
Page 13 of 63

Arizona

$1,105,715

Arkansas

$1,106,612

California

$1,857,270

Colorado

$966,208

Connecticut

$946,106

Delaware

$949,314

District of Columbia

$942,849

Florida

$1,483,919

Georgia

$1,233,901

Hawaii

$879,794

Idaho

$925,161

Illinois

$1,206,246

Indiana

$1,098,455

Iowa

$961,997

Kansas

$967,608

Kentucky

$1,144,748

Louisiana

$1,173,237

Maine

$947,063

Maryland

$1,015,605

Massachusetts

$1,018,690

Michigan

$1,200,813

Minnesota

$980,632

Mississippi

$1,177,592

Missouri

$1,082,121

Montana

$934,260

Nebraska

$899,275

Nevada

$1,011,841

New Hampshire

$858,677

New Jersey

$1,100,267

New Mexico

$1,032,286

New York

$1,398,077

North Carolina

$1,212,817

North Dakota

$893,177
Page 14 of 63

Ohio

$1,247,505

Oklahoma

$1,102,086

Oregon

$987,674

Pennsylvania

$1,241,244

Rhode Island

$910,571

South Carolina

$1,126,495

South Dakota

$923,416

Tennessee

$1,172,233

Texas

$1,658,437

Utah

$880,310

Vermont

$879,920

Virginia

$1,081,945

Washington

$1,052,352

West Virginia

$1,112,042

Wisconsin

$1,008,833

Wyoming

$877,446

b. Evaluation and Performance Measurement
i. CDC Evaluation and Performance Measurement Strategy
Recipients are required to work with professional evaluators (either internal or external) to meet
the evaluation and performance reporting requirements of this NOFO by identifying these efforts
in the workplan, evaluation plans, and budget. Therefore, CDC strongly recommends allocating
at least 10% of the total funding award to evaluation and performance monitoring and to
consider both development and implementation costs. For information on developing an
evaluation plan, please refer to the CDC Framework for Program Evaluation in Public Health
(Centers for Disease Control and Prevention. Framework for Program Evaluation in Public
Health. MMWR 1999; 48, No. RR-11.
https://www.cdc.gov/mmwr/preview/mmwrhtml/rr4811a1.htm
Evaluation and performance measurement help demonstrate program accomplishments,
strengthen the evidence for strategy implementation, and guide program improvement for CDC
and recipients.
Throughout the five-year cooperative agreement, CDC will work individually and collectively
with recipients to track the implementation of recipient strategies and activities and assess
progress on achieving the five-year NOFO outcomes. Both the process and outcome evaluation
Page 15 of 63

will seek to answer the following overarching evaluation questions:
Process (Implementation) Evaluation:






To what extent have recipients increased the reach of the program strategies to prevent
and control cardiovascular disease?
To what extent has program strategy implementation led to improved health outcomes
among the identified population(s) at the highest risk of cardiovascular disease?
What factors were associated with effective implementation of the program strategies?
What factors were associated with identifying and addressing social services and support
needs and social determinants of health for populations at the highest risk of
cardiovascular disease?
To what extent can the implemented program strategies be sustained after the NOFO
ends?

Outcome Evaluation:



To what extent have the implemented program strategies contributed to a measurable
change in health outcomes, health equity, and health systems in a defined community,
population, organization, or system?
To what extent have the program strategies contributed to reduced healthcare disparities
and improved health outcomes within populations at the highest risk of cardiovascular
disease?

CDC will use an evaluation approach that consists of (1) ongoing monitoring and evaluation
through the collection and reporting of performance measures, (2) a CDC-led national
evaluation, and (3) recipient-led evaluations.
Performance measures developed for this program correspond to the strategies and outcomes
described in the logic model. Recipients will report all short-term and intermediate performance
measures. Recipients are not required to report long term measures. CDC will work with
recipients on operationalizing and further defining each performance measure, and guidance will
be provided prior to the first reporting period. Performance measures will be reported annually
to CDC, and CDC will manage and analyze the data to assess recipient program progress,
respond to broader technical assistance needs, and report to partners. CDC will analyze
performance measure data annually and develop aggregate performance measure reports to be
disseminated to recipients and other key partners, including federal partners, other funded and
non-funded partners, and policy makers, as appropriate. These aggregate findings may also be
presented during site visits and recipient meetings. In addition to performance measures reported
by recipients, CDC will track additional measures relevant to the program through national
datasets or national evaluation activities.
For the CDC-led national evaluation activities, CDC will lead the design, data collection,
analysis, and reporting. CDC will engage recipients in developing and implementing the
evaluation and recipients will be asked to participate in national evaluation activities such as
surveys, interviews, case studies, and other data collection efforts. Recipients may also be asked
to participate in special studies led by CDC that further explore specific components of the
Page 16 of 63

program or across DHDSP-funded programs. An appropriate level of guidance and support will
be provided to the recipients to ensure their effective participation in the comprehensive
evaluation. CDC will use findings from these evaluation efforts to refine its technical assistance
and, in turn, maximize and sustain program outcomes. Evaluation findings will be shared with
recipients on a regular basis.
For recipient-led evaluations, CDC will assist recipients in developing and implementing
evaluation plans that are useful for state-level program improvement and for the overall
evaluation of the program. For all components of the evaluation, CDC and recipients will only
collect data that will be analyzed and used.
CDC will provide recipients with guidance for developing evaluation plans and reporting
performance measures and evaluation results. CDC will also provide ongoing evaluation
technical assistance and ensure that the tools and services provided best meet the needs of the
recipients. All information will be stored using a secure system. All evaluation findings produced
by CDC and recipients, where appropriate, will contribute to: (1) continuous improvement of
quality and effectiveness of program strategies; (2) the evidence base; (3) documentation and
sharing of lessons learned to support replication and scaling of these program strategies; and (4)
future funding opportunities supported by CDC.
The data collected by CDC for performance measurement and evaluation are directly related to
the implementation of the strategies and the desired outcomes indicated in the logic model. The
data collected for this NOFO for performance measurement and national evaluation do not
include any personally identifiable information. Data being collected are strictly related to the
implementation of the NOFO strategies and shall be used for assessing and reporting progress
and for other pertinent program improvement actions. All performance measure data will be
stored using a secure data system. Recipients will report their performance measure data
annually and will only have access to their data. Over the five-year period of performance, data
will be secured with limited access to authorized CDC program and evaluation staff to the extent
allowed under applicable Federal law. CDC will aggregate data across all recipients to publish
annual and summative reports. Applicants should submit a Data Management Plan (DMP). A
template provided by NCCDPHP can be found at https://www.cdc.gov/chronicdisease/programsimpact/nofo/index.htm . Applicants are not required to use the sample template; however, all
elements included in the template must be addressed.
The table below aligns with the logic model and shows the relationship between the overarching
focus areas, specific strategies, outcomes, and performance measures. Recipients are required
to address all strategies and report all short term and intermediate performance measures.
Strategies

Strategy 1. Track and
Monitor Clinical and
Social Services and
Support Needs Measures
shown to improve health
and wellness, health
care quality, and identify
patients at highest risk

Short-term Outcomes and
Performance Measures (reported by
recipients)

Intermediate
Outcomes and
Performance
Measures (reported
by recipients)
Improved blood
pressure control
among populations
within partner health
Pageand
17 community
of 63
care
settings.
Measure: # and % of

1A: Advance the
adoption and use of
electronic health records
(EHR) or health
information technology
(HIT), to identify, track,
and monitor measures
for clinical and social
services and support
needs to address health
care disparities and
health outcomes for
patients at highest risk of
cardiovascular disease
(CVD) with a focus on
hypertension and high
cholesterol.

Increased use of EHRs or HIT to report,
monitor, and track clinical and social
services and support needs data to
improve detection of health care
disparities and the identification,
management, and treatment of patients
at highest risk of cardiovascular disease,
with a focus on hypertension and high
cholesterol.

1B: Promote the use of
standardized processes
or tools to identify the
social services and
support needs of patient
populations at highest
risk of CVD, with a
focus on hypertension
and high cholesterol, and
monitor and assess the
referral and utilization of
those services, such as
food assistance,
transportation, housing,
childcare, etc.

Increased use of standardized processes
or tools to identify, assess, track, and
address the social services and support
needs of patient populations at highest
risk of CVD.

Measure 1A.: # and % of clinics or
health care systems that have
policies/protocols in place requiring the
use of EHRs and standardized clinical
quality measures to track hypertension
control measures by race, ethnicity, and
other populations of focus.

Measure 1B:# and % of clinics or health
care systems that use standardized
processes or tools to identify, assess,
track, and address the social services and
support needs of patient populations at
highest risk of CVD.

achieved or are
currently maintaining
blood pressure control.
Reduced disparities in
blood pressure control
among populations
within partner health
care and community
settings.
Measure: # and % of
adults within partner
health care and
community settings,
reported by race and
ethnicity, with known
hypertension who have
achieved or are
currently maintaining
blood pressure control.
Increased utilization
of social services
and support among
populations at highest
risk of CVD, with a
focus on hypertension
and high cholesterol.
Measure: # and % of
adults who were
referred to social
services and
support needs and
lifestyle interventions

Page 18 of 63

who access the social
services and support
or participate in
lifestyle interventions.

Strategy 2. Implement
Team-Based Care to
Prevent and Reduce
CVD Risk with a Focus
on Hypertension and
High Cholesterol
Prevention, Detection,
Control, and
Management through
the Mitigation of Social
Support Barriers to
Improve Outcomes.
2A: Advance the use of
health information
systems that support
team-based care to
monitor population
health with a focus on
health disparities,
hypertension, and high
cholesterol.

Increased use of EHRs or HIT to
support communication and
coordination among care team members
to monitor and address
patients' hypertension and high
cholesterol.

2B: Assemble or create
multidisciplinary teams
(e.g., nurses, nurse
practitioners,
pharmacists,
nutritionists, physical
therapists, social
workers, and
community-based
workers) to identify
patients' social services
and support needs and to
improve the
management and
treatment of
hypertension and high
cholesterol.

Increased use of multidisciplinary care
teams adhering to evidence-based
guidelines to address patients' social
services and support needs and improve
the management and treatment of
hypertension and high cholesterol.

Measure 2A: # and % of clinics or
health systems that have
policies/protocols in place requiring the
use of clinical data from EHRs or HIT to
support communication within the care
team to coordinate care for patients with
hypertension and high cholesterol.

Measure 2B: # of adults within clinics or
health care systems that use
multidisciplinary care teams that adhere
to evidence-based guidelines.

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2C: Build and manage a
coordinated network of
multidisciplinary
partnerships that address
identified barriers to
social services and
support needs (e.g.,
childcare, transportation,
language translation,
food assistance, and
housing) within
populations at highest
risk of CVD.

Increased multidisciplinary partnerships
that address identified barriers to social
services and support needs
within populations at highest risk of
CVD.

Measure 2C:# and type of social
services and support within the
recipient’s network that address the
social needs at highest risk of CVD.

Strategy 3. Link
Community resources
and Clinical Services
That Support BiDirectional Referrals,
Self-management, and
Lifestyle Change to
Address Social
Determinants That Put
the Priority Populations
at Increased Risk
of Cardiovascular
Disease with a Focus on
Hypertension and High
Cholesterol.
3A: Create and enhance
community-clinical links
to identify SDOH (e.g.,
housing, transportation,
access to care, and
community resources)
and respond to the social
services and support
needs of populations
at highest risk of
cardiovascular disease
with a focus on

Increased community clinical links to
identify and respond to social services
and support needs of populations at
highest risk of cardiovascular disease
with a focus on hypertension and high
cholesterol.

Measure 3A: # of adults with
hypertension, high cholesterol, or other
risk of cardiovascular disease who are
referred to lifestyle change programs or
Page 20 of 63

hypertension and high
cholesterol.

3B: Identify and deploy
dedicated CHWs (or
their equivalents) to
provide a continuum of
care and services which
extend the benefits of
clinical interventions
and address social
services and support
needs leading to optimal
health outcomes.

social services and support.

Increased engagement of CHWs (or
their equivalents) to provide a
continuum of care extending clinical
interventions and addressing social
services and support needs.
Measure 3B: # of CHWs (or their
equivalent) who engage with community
organizations to extend care beyond the
clinical environment to address social
services and support needs for those with
hypertension, high cholesterol, or other
risk of cardiovascular disease.
Increased use of SMBP with clinical
support within populations at highest
risk of hypertension.

3C: Promote use of selfmeasured blood pressure
monitoring (SMBP) with
clinical support
within populations at
Measure 3C: # of patients participating
highest risk of
in SMBP programs with clinical support.
hypertension.
ii. Applicant Evaluation and Performance Measurement Plan
Applicants must provide an evaluation and performance measurement plan that demonstrates
how the recipient will fulfill the requirements described in the CDC Evaluation and Performance
Measurement and Project Description sections of this NOFO. At a minimum, the plan must
describe:


How the applicant will collect the performance measures, respond to the evaluation
questions, and use evaluation findings for continuous program quality improvement.



How key program partners will participate in the evaluation and performance
measurement planning processes.



Available data sources, feasibility of collecting appropriate evaluation and performance
data, and other relevant data information (e.g., performance measures proposed by the
applicant)



Plans for updating the Data Management Plan (DMP) as new pertinent information
becomes available. If applicable, throughout the lifecycle of the project. Updates to
DMP should be provided in annual progress reports. The DMP should provide a
description of the data that will be produced using these NOFO funds; access to data;
data standards ensuring released data have documentation describing methods of
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collection, what the data represent, and data limitations; and archival and long-term data
preservation plans. For more information about CDC’s policy on the DMP,
see https://www.cdc.gov/grants/additional-requirements/ar-25.html.
Where the applicant chooses to, or is expected to, take on specific evaluation studies, the
applicant should be directed to:


Describe the type of evaluations (i.e., process, outcome, or both).



Describe key evaluation questions to be addressed by these evaluations.



Describe other information (e.g., measures, data sources).

Recipients will be required to submit a more detailed Evaluation and Performance Measurement
plan, including a DMP, if applicable, within the first 6 months of award, as described in the
Reporting Section of this NOFO.
In addition, the applicant's evaluation and performance measurement plans should:








Describe data collection approaches, measures, and data sources.
Align each evaluation question with the approach, instruments/data sources, and timeline.
Propose analyses for at least two time points (baseline and follow-up), and assess
program impact on any intended health disparate populations.
Describe how the applicant will use GIS to identify priority populations in census
geographies disproportionately impacted by cardiovascular disease.
Describe how much of the overall funding amount will be allocated to evaluation and
performance measurement.
Describe how applicants will work with professional evaluators (either internal or
external) to meet the evaluation and performance measurement requirements.
Use the NDCCPHP DMP template at: https://www.cdc.gov/chronicdisease/programsimpact/nofo/index.htm

Applicants must demonstrate a clear plan to work with professional evaluators (either internal or
external) to meet the evaluation and performance reporting requirements of this NOFO by
identifying these efforts in the workplan, evaluation plans, and budget. Therefore, CDC strongly
recommends allocating at least 10% of the total funding award to evaluation and performance
monitoring and to consider both development and implementation costs. For information on
developing an evaluation plan, please refer to the CDC Framework for Program Evaluation in
Public Health (Centers for Disease Control and Prevention. Framework for Program Evaluation
in Public Health. MMWR 1999; 48, No. RR-11)
https://www.cdc.gov/mmwr/preview/mmwrhtml/rr4811a1.htm .
For the detailed Evaluation and Performance Measurement Plan due 6 months post award, CDC
will work closely with recipients to develop the detailed plan to ensure that it is appropriate for
the activities conducted as part of this cooperative agreement, for compliance with the
monitoring and evaluation guidance established by CDC, or other guidance otherwise applicable
to this cooperative agreement. CDC will provide additional guidance for developing the
Evaluation and Performance Measurement Plan.
c. Organizational Capacity of Recipients to Implement the Approach
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Applicants must describe their organizational capacity to carry out all of the strategies outlined in
the Activities and Strategies section. CDC anticipates that all applicants will be able to
demonstrate capacity to carry out the activities outlined over the 5-year period of performance.
Organizational Capacity
Applicants must:









Describe how they will coordinate efforts with other federally- and privately- funded
programs within the state to leverage resources and maximize reach and impact to
address SDOH and social services and support needs related to CVD, specific to
hypertension and high cholesterol in their state and their overall approach to addressing
the populations at the highest risk.
Describe their capacity to manage programs and resources ensuring the administrative,
financial, and staff support necessary to sustain activities. This includes describing an
adequate staffing plan, providing CVs or resumes for proposed personnel, an
organizational chart, and a project management structure that clearly defines staff roles
and reporting structure, as it applies to this funding opportunity. Applicants must name
these files CVs/Resumes” and “Organizational Charts” respectively, and upload them as
PDFs in grants.gov. Describe previous experience in the management of CVD programs
specific to hypertension and high cholesterol within populations at the highest risk.
Describe a dedicated staff person explicitly included in the work plan and budget, who
will focus on health inequities and build relationships at the designated levels to decrease
health care disparities and advance health equity.
Describe the organization/proposed program plan that demonstrates the ability to
document and disseminate evaluation findings, outcomes, and recommendations,
including the outcomes and achievements resulting from collaborative work with
partners.
Describe how program performance will be monitored and how the program will be
adjusted to address identified problems.

Collaborations
Applicants must:




Describe how they will collaborate with CDC-funded programs and health equity subject
matter experts in the state health department.
Describe how they will establish or partner with learning collaboratives (LC) or
collaborate with organizations outside the state health department.
Provide Letters of Support or Memorandums of Agreement from proposed LC
partners. These files should be named "MOUs/MOAs.Applicant Name" and uploaded as
a PDF file at www.grants.gov

d. Work Plan
Applicants must submit a detailed work plan for Year 1 of the award and provide a general
summary of work plan activities for Years 2–5. The work plan must describe how the applicant
will address all strategies to achieve NOFO outcomes. These activities must be in alignment
Page 23 of 63

with the NOFO logic model and should include the required performance measures for
accomplishing tasks. Baselines, Year 1 targets, and data sources should be provided for all
performance measures (short-term and intermediate).
A sample work plan format is provided below. Applicants are not required to use the sample
work plan format but are required to include all the elements. Applicants must name this file
“Workplan_Name of Applicant” and upload it as a PDF file. CDC will provide feedback and
technical assistance to award recipients to finalize the work plan activities post-award. The
Workplan is not included in the 20-page limit.
Sample DP-23-0004 Work Plan format

Strategy 1: Track and Monitor Clinical and Social Services and Support Needs Measures
Shown to Improve Health and Wellness, Health Care Quality, and Identify Patients at the
Highest Risk of Cardiovascular Disease (CVD) with a Focus on Hypertension and High
Cholesterol.
1A: Advance the adoption and use of electronic health records (EHR) or health
information technology (HIT), to identify, track, and monitor measures for clinical and
social services and support needs to address health care disparities and health outcomes for
patients at highest risk of cardiovascular disease (CVD) with a focus on hypertension and
high cholesterol.
Activities
Responsible Start
Position/Par Date
/
ty
Completion Date

Short Term Performance Outcome
Increased use of EHRs or HIT to report,
monitor, and track clinical and social services
and support needs data to improve detection of
health care disparities and the identification,
management, and treatment of patients at
highest risk of CVD, with a focus on
hypertension and high cholesterol.

Short Term Performance Measures
Measure 1A.: # and % of clinics or health
care systems that have policies/protocols
in place requiring the use of EHRs and
standardized clinical quality measures to
track hypertension control measures by
race, ethnicity, and other populations of
focus.

1B: Promote the use of standardized processes or tools to identify the social services and
support needs of patient populations at highest risk of CVD, with a focus on hypertension
and high cholesterol, and monitor and assess the referral and utilization of those services,
such as food assistance, transportation, housing, childcare, etc.
Activities
Responsible Start
Position/Par Date
/
ty
Completion Date

Page 24 of 63

Short Term Performance Outcome
Increased use of standardized processes or
tools to identify, assess, track, and address the
social services and support needs of patient
populations at highest risk of CVD.

Short Term Performance Measure
Measure 1B:# and % of clinics or health
care systems that use standardized
processes or tools to identify, assess,
track, and address the social services and
support needs of patient populations at
highest risk of CVD.

Years 2-5
Provide a general summary of work plan activities that address Strategy 1 proposed for
Years 2-5 (maximum of one page narrative).

Strategy 2: Implement Team-Based Care to Prevent and Reduce CVD Risk with a Focus on
Hypertension and High Cholesterol Prevention, Detection, Control, and Management
through the Mitigation of Social Support Barriers to Improve Outcomes.
2A: Advance the use of health information systems that support team-based care to
monitor population health with a focus on health disparities, hypertension, and high
cholesterol.
Activities
Responsible Start
Position/Par Date
/
ty
Completion Date

Short Term Outcome
Increased use of EHRs or HIT to support
communication and coordination among care
team members to monitor and address
patients’ hypertension and high cholesterol.

Short Term Performance Measure
Measure 2A: # and % of clinics or health
systems that have policies/protocols in
place requiring the use of clinical data
from EHRs or HIT to support
communication within the care team to
coordinate care for patients with
hypertension and high cholesterol.
2B: Assemble or create multidisciplinary teams (e.g., nurses, nurse practitioners,
pharmacists, nutritionists, physical therapists, social workers, and community-based
workers) to identify patients' social services and support needs and to improve the
management and treatment of hypertension and high cholesterol.
Activities
Responsible Start
Position/Par Date
/
ty
Completion Date

Page 25 of 63

Short Term Outcome
Increased use of multidisciplinary care teams
adhering to evidence-based guidelines to
address patients' social services and support
needs and improve the management and
treatment of hypertension and high
cholesterol.

Short Term Performance Measure
Measure 2B: # of adults within clinics or
health care systems that use
multidisciplinary care teams that adhere
to evidence-based guidelines.

2C: Build and manage a coordinated network of multi-disciplinary partnerships that
address identified barriers to social services and support needs (e.g., childcare,
transportation, language translation, food assistance, and housing) within populations at
highest risk of CVD.
Activities
Responsible Start
Position/Par Date
/
ty
Completion Date

Short Term Outcome
Increased multidisciplinary partnerships that
address identified barriers to social services
and support needs within populations at
highest risk of CVD.

Short Term Performance Measure
Measure 2C:# and type of social services
and support within the recipient’s
network that address the social needs at
highest risk of CVD.

Years 2-5
Provide a general summary of work plan activities that address Strategy 2 proposed for
Years 2-5 (maximum of one page narrative).

Strategy 3: Link Community Resources and Clinical Services that support bidirectional
referrals, self-management, and lifestyle change to address social determinants that put
the priority populations at increased risk of cardiovascular disease with a focus on
hypertension and high cholesterol.
3A: Create and enhance community-clinical links to identify SDoH (e.g., inferior housing,
lack of transportation, inadequate access to care, and limited community resources) and
respond to the social services and support needs of populations at highest risk of CVD with
a focus on hypertension and high cholesterol.
Activities
Responsible Start
Position/Par Date
/
ty
Completion Date

Page 26 of 63

Short Term Outcome
Increased community clinical links to identify
and respond to social services and support
needs for populations at highest risk of
cardiovascular disease with a focus on
hypertension and high cholesterol.

Short Term Performance Measure
Measure 3A: # of adults with
hypertension, high cholesterol, or other
risk of cardiovascular disease who are
referred to lifestyle change programs or
social services and support.

3B: Identify and deploy dedicated CHWs (or their equivalents) to provide a continuum of
care and services which extend the benefits of clinical interventions and address social
services and support needs leading to optimal health outcomes.
Activities
Responsible Start
Position/Par Date
/
C
ty
ompletion Date

Short Term Outcome
Increased engagement of CHWs (or their
equivalents) to provide a continuum of care
extending clinical interventions and
addressing social services and support needs.

Short Term Performance Measure
Measure 3B: # of CHWs (or their
equivalent) who engage with community
organizations to extend care beyond the
clinical environment to address social
services and support needs for those with
hypertension, high cholesterol, or other
risk of cardiovascular disease.
3C: Promote use of self-measured blood pressure monitoring (SMBP) with clinical support
within populations at highest risk of hypertension.
Activities
Responsible Start
Position/Par Date
/
Co
ty
mpletion Date

Short Term Outcome
Increased use of SMBP with clinical support
within populations at highest risk of
hypertension.

Short Term Performance Measure
Measure 3C: # of patients participating in
SMBP programs with clinical support.

Years 2-5
Provide a general summary of work plan activities that address Strategy 3 proposed for

Page 27 of 63

Years 2-5 (maximum of one page narrative).

Intermediate Outcomes

Intermediate Required Performance Measures

Improved blood pressure control
among populations within partner
health care and community settings.

Measure: # and % of adults within partner health care
and community settings with known hypertension
who have achieved or are currently maintaining blood
pressure control.

Measure: # and % of adults within partner health care
Reduced disparities in blood pressure
and community settings, reported by race and
control among populations within
ethnicity, with known hypertension who have
partner health care and community
achieved or are currently maintaining blood pressure
settings.
control.
Increased utilization of social services Measure: # and % of adults who were referred to
and support among populations at
social services and support needs and lifestyle
highest risk of CVD, with a focus on interventions who access the social services and
hypertension and high cholesterol.
support or participate in lifestyle interventions.

e. CDC Monitoring and Accountability Approach
Monitoring activities include routine and ongoing communication between CDC and recipients,
site visits, and recipient reporting (including work plans, performance, and financial reporting).
Consistent with applicable grants regulations and policies, CDC expects the following to be
included in post-award monitoring for grants and cooperative agreements:


Tracking recipient progress in achieving the desired outcomes.



Ensuring the adequacy of recipient systems that underlie and generate data reports.



Creating an environment that fosters integrity in program performance and results.

Monitoring may also include the following activities deemed necessary to monitor the award:


Ensuring that work plans are feasible based on the budget and consistent with the intent
of the award.



Ensuring that recipients are performing at a sufficient level to achieve outcomes
within stated timeframes.



Working with recipients on adjusting the work plan based on achievement of
outcomes, evaluation results and changing budgets.



Monitoring performance measures (both programmatic and financial) to assure
satisfactory performance levels.

Page 28 of 63

Monitoring and reporting activities that assist grants management staff (e.g., grants management
officers and specialists, and project officers) in the identification, notification, and management
of high-risk recipients.
The proposed work plan and performance measures will be reviewed annually by the project
officer and evaluation staff, and may need to be altered to better reflect program activities as
outlined in the NOFO. Post-award cooperative agreement monitoring and provision of technical
assistance and training will include:







Ensuring that work plans are feasible, fiscally responsible, consistent with the intent of
the award, and have acceptable milestones and timelines.
Ensuring that the activities outlined in the NOFO are being completed.
Assisting recipients in adjusting work plan activities based on achievement of objectives
or budget changes.
Communicating as needed, or at minimum monthly, with the project coordinator and
other program staff on conference calls/webinars.
Sponsoring webinars and other meetings/trainings associated with the NOFO.
Providing tools/resources aligned with program activities and NOFO outcomes,
assessment, and implementation support.

CDC will analyze performance measurement data to review progress and identify technical
assistance needs for all NOFO strategies on an annual basis. The performance measure data will
be triangulated with other internal and external sources of appropriate data to arrive at a rational
assessment of progress. Findings from the annual analysis of performance measure data will be
used to identify areas of program improvement, broader technical assistance needs, and for
accountability reporting. CDC will develop annual, aggregate and individual performance
measure reports to be disseminated to recipients, federal partners, other funded and non-funded
partners, policy makers, and the public as appropriate. Reports may also be presented during site
visits and recipient meetings. In addition to performance measures reported by recipients, CDC
will track other measures that are relevant to the program through national datasets and national
evaluation activities.

f. CDC Program Support to Recipients
CDC will be substantially involved beyond site visits and regular performance and financial
monitoring during the period of performance. Substantial involvement means that the recipient
can expect federal programmatic partnership in carrying out efforts under the award. CDC will
work in partnership with the recipient to ensure the success of the cooperative agreement by:





Supporting recipients in implementing cooperative agreement requirements and meeting
program outcomes.
Assisting recipients in advancing program activities to achieve project outcomes.
Providing scientific subject matter expertise and resources in support of the required
strategies.
Collaborating with recipients to develop and implement evaluation plans that align with
CDC evaluation activities.
Page 29 of 63












Providing technical assistance on recipients’ evaluation and performance measurement
plans.
Providing technical assistance to define and operationalize performance measures and
reports.
Engaging in and facilitating varied means of communication and peer sharing
opportunities among recipients and with CDC to communicate and share tools and
resources.
Establishing learning opportunities to facilitate the sharing of information among
recipients.
Providing professional development and training opportunities – either in person or
through virtual, web-based training formats – for the purpose of sharing the latest
science, best practices, success stories, and program models.
Participating in relevant meetings, committees, conference calls, and working groups
related to the cooperative agreement requirements to achieve outcomes.
Coordinating communication and program links with other CDC programs and federal
agencies, such as the Health Resources and Services Administration (HRSA), Centers for
Medicare & Medicaid Services (CMS), Indian Health Service (IHS), and the National
Institutes of Health (NIH), as appropriate.
Providing surveillance technical assistance and state-specific data collected by CDC.
Translating and disseminating lessons learned through publications, meetings, and other
means on promising and best practices to expand the evidence base.

B. Award Information
1. Funding Instrument Type:
CA (Cooperative Agreement)
CDC's substantial involvement in this program appears in the CDC Program Support to
Recipients Section.
2. Award Mechanism:
U58
3. Fiscal Year:
2023
4. Approximate Total Fiscal Year Funding:
$55,000,000
5. Total Period of Performance Funding:
$275,000,000
This amount is subject to the availability of funds.
Estimated Total Funding:
$275,000,000
6. Total Period of Performance Length:
Page 30 of 63

5 year(s)
year(s)
7. Expected Number of Awards:
51
8. Approximate Average Award:
$1,000,000
Per Budget Period
9. Award Ceiling:
$2,000,000
Per Budget Period
This amount is subject to the availability of funds.
10. Award Floor:
$850,000
Per Budget Period
11. Estimated Award Date:
May 30, 2023
12. Budget Period Length:
12 month(s)
Throughout the project period, CDC will continue the award based on the availability of funds,
the evidence of satisfactory progress by the recipient (as documented in required reports), and
the determination that continued funding is in the best interest of the federal government. The
total number of years for which federal support has been approved (project period) will be shown
in the “Notice of Award.” This information does not constitute a commitment by the federal
government to fund the entire period. The total period of performance comprises the initial
competitive segment and any subsequent non-competitive continuation award(s).
13. Direct Assistance
Direct Assistance (DA) is not available through this NOFO.
If you are successful and receive a Notice of Award, in accepting the award, you agree that the
award and any activities thereunder are subject to all provisions of 45 CFR part 75, currently in
effect or implemented during the period of the award, other Department regulations and policies
in effect at the time of the award, and applicable statutory provisions.
C. Eligibility Information
1. Eligible Applicants
Eligibility Category:
00 (State governments)
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25 (Others (see text field entitled "Additional Information on Eligibility" for clarification))
Additional Eligibility Category:
Government Organizations:
State governments or their bona fide agents (includes the District of Columbia)
2. Additional Information on Eligibility
Per the program’s authorizing statute or regulation: Sec 317(a) of the Public Health Service Act
[42 USC 247b] only State governments, including the District of Columbia, or their bona fide
agents are eligible to apply. Local health departments are eligible to compete under a separate
NOFO (The Innovative Cardiovascular Health Program), and Tribes and Tribal-serving
organizations are and will continue to be funded under separate NOFOs
(https://www.cdc.gov/healthytribes/index.htm).
FY22 House Report language asserts the significant increases to DHDSP’s budget allocations
should be directed to “support, strengthen, and expand current evidence-based initiatives at the
State, local, tribal, and territorial level.” Committee language further supports a continuation of
DHDSP’s current efforts and “recognizes the vital importance of addressing cardiovascular
disease among women and underserved communities, communities of color, those communities
with limited access to information about cardiovascular health disease, and communities at risk
for delaying regular monitoring of cardiovascular health as a result of the COVID–19 pandemic.
The Committee supports CDC’s efforts to improve our understanding of the outcomes and health
effects of COVID–19 infection, including cardiovascular disease.” [House Committee Report
117-96, p. 89. Available at: CRPT-117hrpt96.pdf (congress.gov)]
More recently, FY23 House Report language directs efforts to “support, strengthen, and expand
evidence-based initiatives at the State, local, tribal, and territorial level. The Committee
recognizes the vital importance of addressing cardiovascular disease among women, particularly
women of color, and further recognizes that the resulting costs to the health care system of
unrecognized cardiovascular disease in women can be substantially reduced with appropriate
public awareness and prevention”. [FY23 House Report 117-403, p. 80. Available at:CRPT117hrpt403.pdf (congress.gov)] FY23 Explanatory Statement asserts the agreement includes an
increase to strengthen and expand evidence-based heart disease and stroke prevention activities
focused on high risk populations.
Applicants should refer to the funding table for specific funding amounts for each state.
3. Justification for Less than Maximum Competition
N/A
4. Cost Sharing or Matching
Cost Sharing / Matching Requirement:
No
Page 32 of 63

5. Maintenance of Effort
Maintenance of effort is not required for this program.
D. Application and Submission Information
1. Required Registrations
An organization must be registered at the three following locations before it can submit an
application for funding at www.grants.gov.
PLEASE NOTE: Effective April 4, 2022, applicants must have a Unique Entity Identifier
(UEI) at the time of application submission (SF-424, field 8c). The UEI is generated as part of
SAM.gov registration. Current SAM.gov registrants have already been assigned their UEI and
can view it in SAM.gov and Grants.gov. Additional information is available on the GSA website,
SAM.gov, and Grants.gov- Finding the UEI.
a. Unique Entity Identifier (UEI):
All applicant organizations must obtain a Unique Entity Identifier (UEI) number by registering
in SAM.gov prior to submitting an application. A UEI number is a unique twelve-digit
identification number assigned to the registering organization.
If funds are awarded to an applicant organization that includes sub-recipients, those subrecipients must provide their UEI numbers before accepting any funds.
b. System for Award Management (SAM):
The SAM is the primary registrant database for the federal government and the repository into
which an entity must submit information required to conduct business as a recipient. All
applicant organizations must register with SAM, and will be assigned a SAM number and a
Unique Entity Identifier (UEI). All information relevant to the SAM number must be current at
all times during which the applicant has an application under consideration for funding by CDC.
If an award is made, the SAM information must be maintained until a final financial report is
submitted or the final payment is received, whichever is later. The SAM registration process can
require 10 or more business days, and registration must be renewed annually. Additional
information about registration procedures may be found at SAM.gov and the SAM.gov
Knowledge Base.
c. Grants.gov:
The first step in submitting an application online is registering your organization
at www.grants.gov, the official HHS E-grant Web site. Registration information is located at the
"Applicant Registration" option at www.grants.gov.
All applicant organizations must register at www.grants.gov. The one-time registration process

Page 33 of 63

usually takes not more than five days to complete. Applicants should start the registration
process as early as possible.
Step System

1

Requirements

Duration

Follow Up

For SAM
1. Go to SAM.gov and designate
Customer
System for an E-Biz POC (You will need to
Service
3-5 Business Days but up
Award
have an active SAM account
Contact https://
to 2 weeks and must be
Management before you can register on
fsd.gov/ fsdrenewed once a year
(SAM)
grants.gov). The UEI is generated
gov/
as part of your registration.
home.do Calls:
866-606-8220

1. Set up an individual account in
Grants.gov using organization's
new UEI number to become an
Authorized
It takes one day (after you
Organization Representative
enter the EBiz POC name
(AOR)
Register early!
and EBiz POC email in
2. Once the account is set up the SAM) to receive a UEI
2
Grants.gov
Applicants can
E-BIZ POC will be notified via
(SAM) which will allow
register within
email
you to register with
minutes.
3. Log into grants.gov using the Grants.gov and apply for
password the E-BIZ POC received federal funding.
and create new password
4. This authorizes the AOR to
submit applications on behalf of
the organization
2. Request Application Package
Applicants may access the application package at www.grants.gov.
3. Application Package
Applicants must download the SF-424, Application for Federal Assistance, package associated
with this notice of funding opportunity at www.grants.gov.
4. Submission Dates and Times
If the application is not submitted by the deadline published in the NOFO, it will not be
processed. Office of Grants Services (OGS) personnel will notify the applicant that their
application did not meet the deadline. The applicant must receive pre-approval to submit a paper
application (see Other Submission Requirements section for additional details). If the applicant is
authorized to submit a paper application, it must be received by the deadline provided by OGS.
a. Letter of Intent Deadline (must be emailed)
b. Application Deadline
Page 34 of 63

Number Of Days from Publication 60
04/25/2023
11:59 pm U.S. Eastern Time, at www.grants.gov. If Grants.gov is inoperable and cannot receive
applications, and circumstances preclude advance notification of an extension, then applications
must be submitted by the first business day on which Grants.gov operations resume.
Due Date for Information Conference Call
The National Cardiovascular Health Program
Applicant Informational Webinar
Thursday, March 9, 2023
2:00pm - 3:00pm ET

Click the link below to join the webinar:
https://cdc.zoomgov.com/j/1604944328?pwd=VXJNUmZ6TFE4VE0wcVRUVVV3b21HUT09
Or join by phone:
US: +1 669 254 5252 or +1 646 828 7666 or +1 646 964 1167 or +1 551 285 1373 or +1 669
216 1590 or +1 415 449 4000
Webinar ID: 160 494 4328
Passcode: 51291371

Additional information about this and other DHDSP funding opportunities may be found at:
https://www.cdc.gov/dhdsp/funding-opps/index.htm
Questions about this NOFO may be submitted via email: [email protected]
Responses will be posted to the NOFO informational website.

5. Pre-Award Assessments
Risk Assessment Questionnaire Requirement
CDC is required to conduct pre-award risk assessments to determine the risk an applicant poses
to meeting federal programmatic and administrative requirements by taking into account issues
such as financial instability, insufficient management systems, non-compliance with award
conditions, the charging of unallowable costs, and inexperience. The risk assessment will include
an evaluation of the applicant’s CDC Risk Questionnaire, located
at https://www.cdc.gov/grants/documents/PPMR-G-CDC-Risk-Questionnaire.pdf, as well as a
review of the applicant’s history in all available systems; including OMB-designated repositories
of government-wide eligibility and financial integrity systems (see 45 CFR 75.205(a)), and other
sources of historical information. These systems include, but are not limited to: FAPIIS
(https://www.fapiis.gov/), including past performance on federal contracts as per Duncan Hunter
Page 35 of 63

National Defense Authorization Act of 2009; Do Not Pay list; and System for Award
Management (SAM) exclusions.
CDC requires all applicants to complete the Risk Questionnaire, OMB Control Number 09201132 annually. This questionnaire, which is located
at https://www.cdc.gov/grants/documents/PPMR-G-CDC-Risk-Questionnaire.pdf, along with
supporting documentation must be submitted with your application by the closing date of the
Notice of Funding Opportunity Announcement. If your organization has completed CDC’s Risk
Questionnaire within the past 12 months of the closing date of this NOFO, then you must submit
a copy of that questionnaire, or submit a letter signed by the authorized organization
representative to include the original submission date, organization’s EIN and UEI.
When uploading supporting documentation for the Risk Questionnaire into this application
package, clearly label the documents for easy identification of the type of documentation. For
example, a copy of Procurement policy submitted in response to the questionnaire may be
labeled using the following format: Risk Questionnaire Supporting Documents _ Procurement
Policy.
Duplication of Efforts
Applicants are responsible for reporting if this application will result in programmatic,
budgetary, or commitment overlap with another application or award (i.e. grant, cooperative
agreement, or contract) submitted to another funding source in the same fiscal
year. Programmatic overlap occurs when (1) substantially the same project is proposed in more
than one application or is submitted to two or more funding sources for review and funding
consideration or (2) a specific objective and the project design for accomplishing the objective
are the same or closely related in two or more applications or awards, regardless of the funding
source. Budgetary overlap occurs when duplicate or equivalent budgetary items (e.g.,
equipment, salaries) are requested in an application but already are provided by another
source. Commitment overlap occurs when an individual’s time commitment exceeds 100
percent, whether or not salary support is requested in the application. Overlap, whether
programmatic, budgetary, or commitment of an individual’s effort greater than 100 percent, is
not permitted. Any overlap will be resolved by the CDC with the applicant and the PD/PI prior
to award.
Report Submission: The applicant must upload the report in Grants.gov under “Other
Attachment Forms.” The document should be labeled: "Report on Programmatic, Budgetary,
and Commitment Overlap.”
6. Content and Form of Application Submission
Applicants are required to include all of the following documents with their application package
at www.grants.gov.
7. Letter of Intent
LOI is not requested or required as part of the application for this NOFO.
8. Table of Contents
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(There is no page limit. The table of contents is not included in the project narrative page
limit.): The applicant must provide, as a separate attachment, the “Table of Contents” for the
entire submission package.
Provide a detailed table of contents for the entire submission package that includes all of the
documents in the application and headings in the "Project Narrative" section. Name the file
"Table of Contents" and upload it as a PDF file under "Other Attachment Forms"
at www.grants.gov.
9. Project Abstract Summary
A project abstract is included on the mandatory documents list and must be submitted
at www.grants.gov. The project abstract must be a self-contained, brief summary of the proposed
project including the purpose and outcomes. This summary must not include any proprietary or
confidential information. Applicants must enter the summary in the "Project Abstract Summary"
text box at www.grants.gov.
10. Project Narrative
(Unless specified in the "H. Other Information" section, maximum of 20 pages, single spaced, 12
point font, 1-inch margins, number all pages. This includes the work plan. Content beyond the
specified page number will not be reviewed.)
Applicants must submit a Project Narrative with the application forms. Applicants must name
this file “Project Narrative” and upload it at www.grants.gov. The Project Narrative must
include all of the following headings (including subheadings): Background, Approach,
Applicant Evaluation and Performance Measurement Plan, Organizational Capacity of
Applicants to Implement the Approach, and Work Plan. The Project Narrative must be succinct,
self-explanatory, and in the order outlined in this section. It must address outcomes and activities
to be conducted over the entire period of performance as identified in the CDC Project
Description section. Applicants should use the federal plain language guidelines and Clear
Communication Index to respond to this Notice of Funding Opportunity. Note that recipients
should also use these tools when creating public communication materials supported by this
NOFO. Failure to follow the guidance and format may negatively impact scoring of the
application.
a. Background
Applicants must provide a description of relevant background information that includes the
context of the problem (See CDC Background).
b. Approach
i. Purpose
Applicants must describe in 2-3 sentences specifically how their application will address the
public health problem as described in the CDC Background section.
ii. Outcomes
Page 37 of 63

Applicants must clearly identify the outcomes they expect to achieve by the end of the project
period, as identified in the logic model in the Approach section of the CDC Project Description.
Outcomes are the results that the program intends to achieve and usually indicate the intended
direction of change (e.g., increase, decrease).
iii. Strategies and Activities
Applicants must provide a clear and concise description of the strategies and activities they will
use to achieve the period of performance outcomes. Applicants must select existing evidencebased strategies that meet their needs, or describe in the Applicant Evaluation and Performance
Measurement Plan how these strategies will be evaluated over the course of the project period.
See the Strategies and Activities section of the CDC Project Description.
1. Collaborations
Applicants must describe how they will collaborate with programs and organizations either
internal or external to CDC. Applicants must address the Collaboration requirements as
described in the CDC Project Description.
2. Target Populations and Health Disparities
Applicants must describe the specific target population(s) in their jurisdiction and explain how
such a target will achieve the goals of the award and/or alleviate health disparities. The
applicants must also address how they will include specific populations that can benefit from the
program that is described in the Approach section. Applicants must address the Target
Populations and Health Disparities requirements as described in the CDC Project Description.
c. Applicant Evaluation and Performance Measurement Plan
Applicants must provide an evaluation and performance measurement plan that demonstrates
how the recipient will fulfill the requirements described in the CDC Evaluation and Performance
Measurement and Project Description sections of this NOFO. At a minimum, the plan must
describe:


How applicant will collect the performance measures, respond to the evaluation
questions, and use evaluation findings for continuous program quality improvement. The
Paperwork Reduction Act of 1995 (PRA): Applicants are advised that any activities
involving information collections (e.g., surveys, questionnaires, applications, audits, data
requests, reporting, recordkeeping and disclosure requirements) from 10 or more
individuals or non-Federal entities, including State and local governmental agencies, and
funded or sponsored by the Federal Government are subject to review and approval by
the Office of Management and Budget. For further information about CDC’s
requirements under PRA see http://www.hhs.gov/ ocio/policy/collection/.



How key program partners will participate in the evaluation and performance
measurement planning processes.



Available data sources, feasibility of collecting appropriate evaluation and performance
data, data management plan (DMP), and other relevant data information (e.g.,
performance measures proposed by the applicant).
Page 38 of 63

Where the applicant chooses to, or is expected to, take on specific evaluation studies, they should
be directed to:


Describe the type of evaluations (i.e., process, outcome, or both).



Describe key evaluation questions to be addressed by these evaluations.



Describe other information (e.g., measures, data sources).

Recipients will be required to submit a more detailed Evaluation and Performance Measurement
plan (including the DMP elements) within the first 6 months of award, as described in the
Reporting Section of this NOFO.
d. Organizational Capacity of Applicants to Implement the Approach
Applicants must address the organizational capacity requirements as described in the CDC
Project Description.
11. Work Plan
(Included in the Project Narrative’s page limit)
Applicants must prepare a work plan consistent with the CDC Project Description Work Plan
section. The work plan integrates and delineates more specifically how the recipient plans to
carry out achieving the period of performance outcomes, strategies and activities, evaluation and
performance measurement.
12. Budget Narrative
Applicants must submit an itemized budget narrative. When developing the budget narrative,
applicants must consider whether the proposed budget is reasonable and consistent with the
purpose, outcomes, and program strategy outlined in the project narrative. The budget must
include:


Salaries and wages



Fringe benefits



Consultant costs



Equipment



Supplies



Travel



Other categories



Contractual costs



Total Direct costs



Total Indirect costs

Indirect costs could include the cost of collecting, managing, sharing and preserving data.
Page 39 of 63

Indirect costs on grants awarded to foreign organizations and foreign public entities and
performed fully outside of the territorial limits of the U.S. may be paid to support the costs of
compliance with federal requirements at a fixed rate of eight percent of MTDC exclusive of
tuition and related fees, direct expenditures for equipment, and subawards in excess of
$25,000. Negotiated indirect costs may be paid to the American University, Beirut, and the
World Health Organization.
If applicable and consistent with the cited statutory authority for this announcement, applicant
entities may use funds for activities as they relate to the intent of this NOFO to meet national
standards or seek health department accreditation through the Public Health Accreditation Board
(see: http://www.phaboard.org). Applicant entities to whom this provision applies include state,
local, territorial governments (including the District of Columbia, the Commonwealth of Puerto
Rico, the Virgin Islands, the Commonwealth of the Northern Marianna Islands, American
Samoa, Guam, the Federated States of Micronesia, the Republic of the Marshall Islands, and the
Republic of Palau), or their bona fide agents, political subdivisions of states (in consultation with
states), federally recognized or state-recognized American Indian or Alaska Native tribal
governments, and American Indian or Alaska Native tribally designated organizations. Activities
include those that enable a public health organization to deliver public health services such as
activities that ensure a capable and qualified workforce, up-to-date information systems, and the
capability to assess and respond to public health needs. Use of these funds must focus on
achieving a minimum of one national standard that supports the intent of the NOFO. Proposed
activities must be included in the budget narrative and must indicate which standards will be
addressed.
Vital records data, including births and deaths, are used to inform public health program and
policy decisions. If applicable and consistent with the cited statutory authority for this NOFO,
applicant entities are encouraged to collaborate with and support their jurisdiction’s vital records
office (VRO) to improve vital records data timeliness, quality and access, and to advance public
health goals. Recipients may, for example, use funds to support efforts to build VRO capacity
through partnerships; provide technical and/or financial assistance to improve vital records
timeliness, quality or access; or support vital records improvement efforts, as approved by CDC.
Applicants must name this file “Budget Narrative” and upload it as a PDF file
at www.grants.gov. If requesting indirect costs in the budget, a copy of the indirect cost-rate
agreement is required. If the indirect costs are requested, include a copy of the current negotiated
federal indirect cost rate agreement or a cost allocation plan approval letter for those Recipients
under such a plan. Applicants must name this file “Indirect Cost Rate” and upload it
at www.grants.gov.
Applicants are encouraged to work with professional evaluators (either internal or external) to
meet the evaluation and performance reporting requirements of this NOFO. Therefore, CDC
strongly recommends allocating at least 10% of the total funding award to evaluation and
performance monitoring and to consider both development and implementation costs.
CDC will not consider funding amounts higher than the specified amount for the state indicated
in the table found under the Funding Strategy section.
13. Funds Tracking
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Proper fiscal oversight is critical to maintaining public trust in the stewardship of federal funds.
Effective October 1, 2013, a new HHS policy on subaccounts requires the CDC to set up
payment subaccounts within the Payment Management System (PMS) for all new grant awards.
Funds awarded in support of approved activities and drawdown instructions will be identified on
the Notice of Award in a newly established PMS subaccount (P subaccount). Recipients will be
required to draw down funds from award-specific accounts in the PMS. Ultimately, the
subaccounts will provide recipients and CDC a more detailed and precise understanding of
financial transactions. The successful applicant will be required to track funds by P-accounts/sub
accounts for each project/cooperative agreement awarded. Applicants are encouraged to
demonstrate a record of fiscal responsibility and the ability to provide sufficient and effective
oversight. Financial management systems must meet the requirements as described 45 CFR 75
which include, but are not limited to, the following:


Records that identify adequately the source and application of funds for federally-funded
activities.



Effective control over, and accountability for, all funds, property, and other assets.



Comparison of expenditures with budget amounts for each Federal award.



Written procedures to implement payment requirements.



Written procedures for determining cost allowability.



Written procedures for financial reporting and monitoring.

14. Pilot Program for Enhancement of Employee Whistleblower Protections
Pilot Program for Enhancement of Employee Whistleblower Protections: All applicants will be
subject to a term and condition that applies the terms of 48 Code of Federal Regulations
(CFR) section 3.908 to the award and requires that recipients inform their employees in writing
(in the predominant native language of the workforce) of employee whistleblower rights and
protections under 41 U.S.C. 4712.
15. Copyright Interests Provisions
This provision is intended to ensure that the public has access to the results and accomplishments
of public health activities funded by CDC. Pursuant to applicable grant regulations and CDC’s
Public Access Policy, Recipient agrees to submit into the National Institutes of Health (NIH)
Manuscript Submission (NIHMS) system an electronic version of the final, peer-reviewed
manuscript of any such work developed under this award upon acceptance for publication, to be
made publicly available no later than 12 months after the official date of publication. Also at the
time of submission, Recipient and/or the Recipient’s submitting author must specify the date the
final manuscript will be publicly accessible through PubMed Central (PMC). Recipient and/or
Recipient’s submitting author must also post the manuscript through PMC within twelve (12)
months of the publisher's official date of final publication; however the author is strongly
encouraged to make the subject manuscript available as soon as possible. The recipient must
obtain prior approval from the CDC for any exception to this provision.

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The author's final, peer-reviewed manuscript is defined as the final version accepted for journal
publication, and includes all modifications from the publishing peer review process, and all
graphics and supplemental material associated with the article. Recipient and its submitting
authors working under this award are responsible for ensuring that any publishing or copyright
agreements concerning submitted articles reserve adequate right to fully comply with this
provision and the license reserved by CDC. The manuscript will be hosted in both PMC and the
CDC Stacks institutional repository system. In progress reports for this award, recipient must
identify publications subject to the CDC Public Access Policy by using the applicable NIHMS
identification number for up to three (3) months after the publication date and the PubMed
Central identification number (PMCID) thereafter.
16. Funding Restrictions
Restrictions that must be considered while planning the programs and writing the budget are:


Recipients may not use funds for research.



Recipients may not use funds for clinical care except as allowed by law.



Recipients may use funds only for reasonable program purposes, including personnel,
travel, supplies, and services.



Generally, recipients may not use funds to purchase furniture or equipment. Any such
proposed spending must be clearly identified in the budget.



Reimbursement of pre-award costs generally is not allowed, unless the CDC provides
written approval to the recipient.



Other than for normal and recognized executive-legislative relationships, no funds may
be used for:
o publicity or propaganda purposes, for the preparation, distribution, or use of any
material designed to support or defeat the enactment of legislation before any
legislative body
o the salary or expenses of any grant or contract recipient, or agent acting for such
recipient, related to any activity designed to influence the enactment of
legislation, appropriations, regulation, administrative action, or Executive order
proposed or pending before any legislative body



See Additional Requirement (AR) 12 for detailed guidance on this prohibition
and additional guidance on lobbying for CDC recipients.



The direct and primary recipient in a cooperative agreement program must perform a
substantial role in carrying out project outcomes and not merely serve as a conduit for an
award to another party or provider who is ineligible.

17. Data Management Plan
As identified in the Evaluation and Performance Measurement section, applications involving
data collection or generation must include a Data Management Plan (DMP) as part of their
evaluation and performance measurement plan unless CDC has stated that CDC will take on the
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responsibility of creating the DMP. The DMP describes plans for assurance of the quality of the
public health data through the data's lifecycle and plans to deposit the data in a repository to
preserve and to make the data accessible in a timely manner. See web link for additional
information:
https://www.cdc.gov/grants/additional-requirements/ar-25.html.
18. Other Submission Requirements
a. Electronic Submission:
Applications must be submitted electronically by using the forms and instructions posted for this
notice of funding opportunity at www.grants.gov. Applicants can complete the application
package using Workspace, which allows forms to be filled out online or offline. All application
attachments must be submitted using a PDF file format. Instructions and training for using
Workspace can be found at www.grants.gov under the "Workspace Overview" option.
b. Tracking Number: Applications submitted through www.grants.gov are time/date stamped
electronically and assigned a tracking number. The applicant’s Authorized Organization
Representative (AOR) will be sent an e-mail notice of receipt when www.grants.gov receives the
application. The tracking number documents that the application has been submitted and initiates
the required electronic validation process before the application is made available to CDC.
c. Validation Process: Application submission is not concluded until the validation process is
completed successfully. After the application package is submitted, the applicant will receive a
“submission receipt” e-mail generated by www.grants.gov. A second e-mail message to
applicants will then be generated by www.grants.gov that will either validate or reject the
submitted application package. This validation process may take as long as two business days.
Applicants are strongly encouraged to check the status of their application to ensure that
submission of their package has been completed and no submission errors have occurred.
Applicants also are strongly encouraged to allocate ample time for filing to guarantee that their
application can be submitted and validated by the deadline published in the NOFO. Nonvalidated applications will not be accepted after the published application deadline date.
If you do not receive a “validation” e-mail within two business days of application submission,
please contact www.grants.gov. For instructions on how to track your application, refer to the email message generated at the time of application submission or the Grants.gov Online User
Guide.
https:// www.grants.gov/help/html/help/index.htm? callingApp=custom#t=
Get_Started%2FGet_Started. htm
d. Technical Difficulties: If technical difficulties are encountered at www.grants.gov, applicants
should contact Customer Service at www.grants.gov. The www.grants.gov Contact Center is
available 24 hours a day, 7 days a week, except federal holidays. The Contact Center is available
by phone at 1-800-518-4726 or by e-mail at [email protected]. Application submissions sent
by e-mail or fax, or on CDs or thumb drives will not be accepted. Please note that
www.grants.gov is managed by HHS.

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e. Paper Submission: If technical difficulties are encountered at www.grants.gov, applicants
should call the www.grants.gov Contact Center at 1-800-518-4726 or e-mail them
at [email protected] for assistance. After consulting with the Contact Center, if the technical
difficulties remain unresolved and electronic submission is not possible, applicants may e-mail
CDC GMO/GMS, before the deadline, and request permission to submit a paper application.
Such requests are handled on a case-by-case basis.
An applicant’s request for permission to submit a paper application must:
1. Include the www.grants.gov case number assigned to the inquiry
2. Describe the difficulties that prevent electronic submission and the efforts taken with
the www.grants.gov Contact Center to submit electronically; and
3. Be received via e-mail to the GMS/GMO listed below at least three calendar days before
the application deadline. Paper applications submitted without prior approval will not be
considered.
If a paper application is authorized, OGS will advise the applicant of specific instructions
for submitting the application via email.
E. Review and Selection Process
1. Review and Selection Process: Applications will be reviewed in three phases
a. Phase 1 Review
All applications will be initially reviewed for eligibility and completeness by CDC Office of
Grants Services. Complete applications will be reviewed for responsiveness by the Grants
Management Officials and Program Officials. Non-responsive applications will not advance to
Phase II review. Applicants will be notified that their applications did not meet eligibility and/or
published submission requirements.
b. Phase II Review
A review panel will evaluate complete, eligible applications in accordance with the criteria
below.
i. Approach
ii. Evaluation and Performance Measurement
iii. Applicant’s Organizational Capacity to Implement the Approach
Not more than thirty days after the Phase II review is completed, applicants will be notified
electronically if their application does not meet eligibility or published submission requirements
i. Approach
Maximum Points: 0
Applications will not be scored.
A technical review will be conducted by the CDC Program staff using the criteria noted in
the Phase II Review Criteria Section.

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Program Strategy
Extent to which an applicant:





Describes how they will align with and join an existing, or establish a new, learning
collaborative (LC) that focuses on developing innovative approaches to improve overall
cardiovascular health. The LC must be equipped to apply those approaches to mitigate
social services and support needs and other associated risk factors for CVD with a focus
on high blood pressure, high cholesterol and stroke.
Describes data (e.g., GIS or other data) used to identify priority populations and
communities to be served. At minimum data must reflect highest prevalence of CVDrelated morbidity and mortality outcomes and incorporate SDOH.
Demonstrates through partnerships the ability to increase the percentage of patients 18–
85 years of age who have had a hypertension diagnosis and among those diagnosed,
blood pressure was adequately controlled during the measurement year for the identified
priority populations.

Strategy 1. Track and Monitor Clinical and Social Services and Support Needs Measures Shown
to Improve Health and Wellness, Health Care Quality, and Identify Patients at Highest Risk of
CVD with a Focus on Hypertension and High Cholesterol.
Extent to which an applicant:




Describes how they will advance the adoption and use of electronic health records (EHR)
or health information technology (HIT), to identify, track, and monitor measures for
clinical and social services and support needs to address health care disparities and health
outcomes for patients at highest risk of CVD, with a focus on hypertension and high
cholesterol.
Describes how they will promote the use of standardized processes or tools to identify the
social services and support needs of patient populations at highest risk of CVD, with a
focus on hypertension and high cholesterol, and monitor and assess the referral and
utilization of those services, such as food assistance, transportation, housing, childcare,
etc.

Strategy 2. Implement Team-Based Care to Prevent and Reduce CVD Risk with a Focus on
Hypertension and High Cholesterol Prevention, Detection, Control, and Management through
Mitigation of Social Support Barriers to Improve Outcomes.
Extent to which an applicant:


Describes how they will advance the use of health information systems that support
team-based care to monitor population health with a focus on health disparities,
hypertension, and high cholesterol.

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



Describes how they will assemble or create multi-disciplinary teams (e.g., nurses, nurse
practitioners, pharmacists, nutritionists, physical therapists, social workers, and
community-based workers) to identify patients' social services and support needs and to
improve the management and treatment of hypertension and high cholesterol.
Describes how they will build and manage a coordinated network of multi-disciplinary
partnerships that address identified barriers to social services and support needs (e.g.,
childcare, transportation, language translation, food assistance, and housing) within
populations at highest risk of CVD.

Strategy 3. Link Community Resources and Clinical Services that support Bi-Directional
Referrals, Self-Management, and Lifestyle Change to Address Social Determinants that Put the
Priority Populations at Increased Risk for CVD, with a Focus on Hypertension and High
Cholesterol.
Extent to which an applicant:






Describes how they will create and enhance community-clinical links to identify SDOH
(e.g., inferior housing, lack of transportation, inadequte access to care, and limited
community resources) and respond to social services and support needs of populations at
highest risk of CVD with a focus on hypertension and high cholesterol.
Describes how they will identify and deploy dedicated CHWs (or their equivalents) to
provide a continuum of care and services which extend the benefits of clinical
interventions and address social services and support needs leading to optimal health
outcomes.
Describes how they will promote use of self-measured blood pressure monitoring with
clinical support within populations at highest risk of hypertension.

Work Plan
Extent to which an applicant:



Provides a detailed work plan for the first year of the award.
Provides a work plan which:
o Describes how the applicant will address all strategies to achieve NOFO
outcomes.
o Contains activities in alignment with the NOFO logic model.
o Includes the required performance measures for accomplishing tasks, with
baselines, Year 1 targets, and data sources for all performance measures (shortterm and intermediate).



Describes staff person(s) responsible for activity oversight along with start and end dates.

ii. Evaluation and Performance Measurement
Extent to which an applicant:


Maximum Points: 0

Describes evaluation strategies that include process and outcome evaluation questions.
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







Describes how they will use data, like GIS mapping, to identify their priority
populations.
Describes how multidisciplinary partners (e.g., learning collaborative, state partners, and
community–based organizations) will be engaged in the evaluation and performance
measurement planning process. Details should include partner’s capacity to collect, store,
and disseminate program data.
Describes how evaluation findings will be used for continuous program improvement.
Describes their existing capacity in program evaluation or plans to develop such
expertise. The description should include details of existing capacity to collect and report
on required program data or plans to implement a data collection and reporting system
with a timeline.
Describes how funding is allocated to evaluation and performance measurement. This
should be explicitly described in the Evaluation and Performance Measurement section
and documented in the staffing plans and budget.

iii. Applicant's Organizational Capacity to Implement the
Approach
Organizational Capacity
Extent to which an applicant:









Maximum Points: 0

Describes how they will coordinate efforts with other federally and privately funded
programs within the state to leverage resources and maximize reach and impact to
address SDOH and social support needs related to CVD, specific to hypertension, in their
state and their overall approach to addressing the populations at highest risk.
Describes their capacity to manage programs and resources ensuring the administrative,
financial, and staff support necessary to sustain activities. This includes describing an
adequate staffing plan, providing CVs/Resumes for proposed personnel, an
organizational chart, and a project management structure that clearly defines staff roles
and reporting structure, as it applies to this funding opportunity. Describes previous
experience in management of CVD programs specific to hypertension within the highest
at-risk populations.
Describes a dedicated staff explicitly included in the work plan and budget, who will
focus on health inequities and build relationships at the designated levels to decrease
health care disparities and advance health equity.
Describes the organization/proposed program plan that demonstrates the ability to
document and disseminate evaluation findings, outcomes, and recommendations,
including the outcomes and achievements resulting from collaborative work with
partners.
Describes how program performance will be monitored and how the program will be
adjusted to address identified problems.

Collaborations
Extent to which an applicant:


Describes how they will collaborate with CDC-funded programs and health equity
subject matter experts in the state health department.
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


Describes how they will establish or partner with learning collaboratives (LC) or
collaborate with organizations outside the state health department
Provides Letters of Support or Memorandums of Agreement from proposed LC partners.

Budget
The extent to which an applicant:




Maximum Points: 0

Describes how the budget supports the work plan and evaluation plan.
Provides an accurate and reasonable budget.
Describes how the budget is allocated to evaluation efforts.

c. Phase III Review
Applications will not be scored. A technical review will be conducted by the CDC Program staff
using the criteria noted in the Phase II Review Criteria Section.

Review of risk posed by applicants.
Prior to making a Federal award, CDC is required by 31 U.S.C. 3321 and 41 U.S.C. 2313 to
review information available through any OMB-designated repositories of government-wide
eligibility qualification or financial integrity information as appropriate. See also suspension and
debarment requirements at 2 CFR parts 180 and 376.
In accordance 41 U.S.C. 2313, CDC is required to review the non-public segment of the OMBdesignated integrity and performance system accessible through SAM (currently the
Federal Recipient Performance and Integrity Information System (FAPIIS)) prior to making a
Federal award where the Federal share is expected to exceed the simplified acquisition threshold,
defined in 41 U.S.C. 134, over the period of performance. At a minimum, the information in the
system for a prior Federal award recipient must demonstrate a satisfactory record of executing
programs or activities under Federal grants, cooperative agreements, or procurement awards; and
integrity and business ethics. CDC may make a Federal award to a recipient who does not fully
meet these standards, if it is determined that the information is not relevant to the current Federal
award under consideration or there are specific conditions that can appropriately mitigate the
effects of the non-Federal entity's risk in accordance with 45 CFR §75.207.
CDC’s framework for evaluating the risks posed by an applicant may incorporate results of the
evaluation of the applicant's eligibility or the quality of its application. If it is determined that a
Federal award will be made, special conditions that correspond to the degree of risk assessed
may be applied to the Federal award. The evaluation criteria is described in this Notice of
Funding Opportunity.
In evaluating risks posed by applicants, CDC will use a risk-based approach and may consider
any items such as the following:
(1) Financial stability;
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(2) Quality of management systems and ability to meet the management standards prescribed in
this part;
(3) History of performance. The applicant's record in managing Federal awards, if it is a prior
recipient of Federal awards, including timeliness of compliance with applicable reporting
requirements, conformance to the terms and conditions of previous Federal awards, and if
applicable, the extent to which any previously awarded amounts will be expended prior to future
awards;
(4) Reports and findings from audits performed under subpart F 45 CFR 75 or the reports and
findings of any other available audits; and
(5) The applicant's ability to effectively implement statutory, regulatory, or other requirements
imposed on non-Federal entities.
CDC must comply with the guidelines on government-wide suspension and debarment in 2 CFR
part 180, and require non-Federal entities to comply with these provisions. These provisions
restrict Federal awards, subawards and contracts with certain parties that are debarred, suspended
or otherwise excluded from or ineligible for participation in Federal programs or activities.
2. Announcement and Anticipated Award Dates
Successful applicants can anticipate notice of funding approximately 30 days prior to the project
start date of June 30, 2023.
F. Award Administration Information
1. Award Notices
Recipients will receive an electronic copy of the Notice of Award (NOA) from CDC OGS. The
NOA shall be the only binding, authorizing document between the recipient and CDC. The
NOA will be signed by an authorized GMO and emailed to the Recipient Business Officer listed
in application and the Program Director.
Any applicant awarded funds in response to this Notice of Funding Opportunity will be subject
to annual SAM Registration and Federal Funding Accountability And Transparency Act Of 2006
(FFATA) requirements.
Unsuccessful applicants will receive notification of these results by e-mail with delivery receipt.
2. Administrative and National Policy Requirements
Recipients must comply with the administrative and public policy requirements outlined in 45
CFR Part 75 and the HHS Grants Policy Statement, as appropriate.
Brief descriptions of relevant provisions are available at https://www.cdc.gov/grants/additionalrequirements/index.html.
The HHS Grants Policy Statement is available
at http://www.hhs.gov/sites/default/files/grants/grants/policies-regulations/hhsgps107.pdf.
AR-1: Human Subjects Requirements
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AR-2: Requirements for Inclusion of Women and Racial and Ethnic Minorities in Research
AR-3: Animal Subjects Requirements
AR-9: Paperwork Reduction Act Requirements
AR-10: Smoke-Free Workplace Requirements
AR-11: Healthy People 2030
AR-12: Lobbying Restrictions
AR-13: Prohibition on Use of CDC Funds for Certain Gun Control Activities
AR-14: Accounting System Requirements
AR-16: Security Clearance Requirement
AR-17: Peer and Technical Reviews of Final Reports of Health Studies – ATSDR
AR-21: Small, Minority, And Women-owned Business
AR-22: Research Integrity
AR-24: Health Insurance Portability and Accountability Act Requirements
AR-25: Data Management and Access
AR-26: National Historic Preservation Act of 1966
AR-28: Inclusion of Persons Under the Age of 21 in Research
AR-29: Compliance with EO13513, “Federal Leadership on Reducing Text Messaging while
Driving”, October 1, 2009
AR-30: Information Letter 10-006, - Compliance with Section 508 of the Rehabilitation Act of
1973
AR-31: Research Definition
AR-32: Appropriations Act, General Provisions
AR-33: United States Government Policy for Institutional Oversight of Life Sciences Dual Use
Research of Concern
AR-37: Prohibition on certain telecommunications and video surveillance services or equipment
for all awards issued on or after August 13, 2020
The full text of the Uniform Administrative Requirements, Cost Principles, and Audit
Requirements for HHS Awards, 45 CFR 75, can be found at: https://www.ecfr.gov/cgi-bin/textidx?node=pt45.1.75
Should you successfully compete for an award, recipients of federal financial assistance (FFA)
from HHS will be required to complete an HHS Assurance of Compliance form (HHS 690) in
which you agree, as a condition of receiving the grant, to administer your programs in
compliance with federal civil rights laws that prohibit discrimination on the basis of race, color,
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national origin, age, sex and disability, and agreeing to comply with federal conscience laws,
where applicable. This includes ensuring that entities take meaningful steps to provide
meaningful access to persons with limited English proficiency; and ensuring effective
communication with persons with disabilities. Where applicable, Title XI and Section 1557
prohibit discrimination on the basis of sexual orientation, and gender identity. The HHS Office
for Civil Rights provides guidance on complying with civil rights laws enforced by HHS. See
https://www.hhs.gov/civil-rights/for-providers/provider- obligations/index.html and
https://www.hhs.gov/civil-rights/for- individuals/nondiscrimination/index.html.







For guidance on meeting your legal obligation to take reasonable steps to ensure
meaningful access to your programs or activities by limited English proficient
individuals, see https://www.hhs.gov/civil-rights/for-individuals/special-topics/limitedenglish-proficiency/fact-sheet-guidance/index.html and https://www.lep.gov.
For information on your specific legal obligations for serving qualified individuals with
disabilities, including providing program access, reasonable modifications, and to provide
effective communication, see
http://www.hhs.gov/ocr/civilrights/understanding/disability/index.html.
HHS funded health and education programs must be administered in an environment free
of sexual harassment, see https://www.hhs.gov/civil-rights/for-individuals/sexdiscrimination/index.html.
For guidance on administering your project in compliance with applicable federal
religious nondiscrimination laws and applicable federal conscience protection and
associated anti-discrimination laws, see https://www.hhs.gov/conscience/conscienceprotections/index.html and https://www.hhs.gov/conscience/religiousfreedom/index.html.

3. Reporting
Reporting provides continuous program monitoring and identifies successes and challenges
that recipients encounter throughout the project period. Also, reporting is a requirement
for recipients who want to apply for yearly continuation of funding. Reporting helps CDC and
recipients because it:


Helps target support to recipients;



Provides CDC with periodic data to monitor recipient progress toward meeting the Notice
of Funding Opportunity outcomes and overall performance;



Allows CDC to track performance measures and evaluation findings for continuous
quality and program improvement throughout the period of performance and to determine
applicability of evidence-based approaches to different populations, settings, and
contexts; and



Enables CDC to assess the overall effectiveness and influence of the NOFO.

The table below summarizes required and optional reports. All required reports must be sent
electronically to GMS listed in the “Agency Contacts” section of the NOFO copying the CDC
Project Officer.

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Report
Recipient Evaluation and
Performance Measurement
Plan, including Data
Management Plan (DMP)
Annual Performance Report
(APR). This includes Data on
Performance Measures.

Federal Financial Reporting
Forms
Final Performance and
Financial Report
Payment Management System
(PMS) Reporting

When?
6 months into award

Required?
Yes

No later than 120 days before
end of budget period. Serves as
yearly continuation application.
Data on Performance Measures are
reported annually.
90 days after the end of the budget
period
90 days after end of period of
performance
Quarterly reports due January
30; April 30; July
30; and October 30

Yes

Yes
Yes
Yes

a. Recipient Evaluation and Performance Measurement Plan (required)
With support from CDC, recipients must elaborate on their initial applicant evaluation and
performance measurement plan. This plan must be no more than 20 pages; recipients must
submit the plan 6 months into the award. HHS/CDC will review and approve the recipient’s
monitoring and evaluation plan to ensure that it is appropriate for the activities to be undertaken
as part of the agreement, for compliance with the monitoring and evaluation guidance established
by HHS/CDC, or other guidance otherwise applicable to this Agreement.
Recipient Evaluation and Performance Measurement Plan (required): This plan should provide
additional detail on the following:
Performance Measurement
• Performance measures and targets
• The frequency that performance data are to be collected.
• How performance data will be reported.
• How quality of performance data will be assured.
• How performance measurement will yield findings to demonstrate progress towards
achieving NOFO goals (e.g., reaching target populations or achieving expected outcomes).
• Dissemination channels and audiences.
• Other information requested as determined by the CDC program.
Evaluation
• The types of evaluations to be conducted (e.g. process or outcome evaluations).
• The frequency that evaluations will be conducted.
• How evaluation reports will be published on a publicly available website.
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• How evaluation findings will be used to ensure continuous quality and program improvement.
• How evaluation will yield findings to demonstrate the value of the NOFO (e.g., effect on
improving public health outcomes, effectiveness of NOFO, cost-effectiveness or cost-benefit).
• Dissemination channels and audiences.
HHS/CDC or its designee will also undertake monitoring and evaluation of the defined activities
within the agreement. The recipient must ensure reasonable access by HHS/CDC or its designee
to all necessary sites, documentation, individuals and information to monitor, evaluate and verify
the appropriate implementation the activities and use of HHS/CDC funding under this
Agreement.
b. Annual Performance Report (APR) (required)
The recipient must submit the APR via www.Grantsolutions.gov no later than 120 days prior to
the end of the budget period. This report must not exceed 45 pages excluding administrative
reporting. Attachments are not allowed, but web links are allowed.
This report must include the following:


Performance Measures: Recipients must report on performance measures for each
budget period and update measures, if needed.



Evaluation Results: Recipients must report evaluation results for the work completed to
date (including findings from process or outcome evaluations).



Work Plan: Recipients must update work plan each budget period to reflect any changes
in period of performance outcomes, activities, timeline, etc.



Successes
o Recipients must report progress on completing activities and progress towards
achieving the period of performance outcomes described in the logic model and
work plan.
o Recipients must describe any additional successes (e.g. identified through
evaluation results or lessons learned) achieved in the past year.
o Recipients must describe success stories.



Challenges
o Recipients must describe any challenges that hindered or might hinder their
ability to complete the work plan activities and achieve the period of performance
outcomes.
o Recipients must describe any additional challenges (e.g., identified through
evaluation results or lessons learned) encountered in the past year.



CDC Program Support to Recipients
o Recipients must describe how CDC could help them overcome challenges to
complete activities in the work plan and achieving period of performance
outcomes.
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

Administrative Reporting (No page limit)
o SF-424A Budget Information-Non-Construction Programs.
o Budget Narrative – Must use the format outlined in "Content and Form of
Application Submission, Budget Narrative" section.
o Indirect Cost Rate Agreement.

The recipients must submit the Annual Performance Report via www.Grantsolutions.gov no
later than 120 days prior to the end of the budget period.
c. Performance Measure Reporting (optional)
CDC programs may require more frequent reporting of performance measures than annually in
the APR. If this is the case, CDC programs must specify reporting frequency, data fields, and
format for recipients at the beginning of the award period.
d. Federal Financial Reporting (FFR) (required)
The annual FFR form (SF-425) is required and must be submitted 90 days after the end of the
budget period through the Payment Management System (PMS). The report must include only
those funds authorized and disbursed during the timeframe covered by the report. The final FFR
must indicate the exact balance of unobligated funds, and may not reflect any unliquidated
obligations. There must be no discrepancies between the final FFR expenditure data and the
Payment Management System’s (PMS) cash transaction data. Failure to submit the required
information by the due date may adversely affect the future funding of the project. If the
information cannot be provided by the due date, recipients are required to submit a letter of
explanation to OGS and include the date by which the Grants Officer will receive information.
e. Final Performance and Financial Report (required)
The Final Performance Report is due 90 days after the end of the period of performance. The
Final FFR is due 90 days after the end of the period of performance and must be submitted
through the Payment Management System (PMS). CDC programs must indicate that this report
should not exceed 40 pages. This report covers the entire period of performance and can include
information previously reported in APRs. At a minimum, this report must include the following:


Performance Measures – Recipients must report final performance data for all process
and outcome performance measures.



Evaluation Results – Recipients must report final evaluation results for the period of
performance for any evaluations conducted.



Impact/Results/Success Stories – Recipients must use their performance measure results
and their evaluation findings to describe the effects or results of the work completed over
the project period, and can include some success stories.



A final Data Management Plan that includes the location of the data collected during the
funded period, for example, repository name and link data set(s)



Additional forms as described in the Notice of Award (e.g., Equipment Inventory Report,
Final Invention Statement).

4. Federal Funding Accountability and Transparency Act of 2006 (FFATA)
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Federal Funding Accountability and Transparency Act of 2006 (FFATA), P.L. 109–282, as
amended by section 6202 of P.L. 110–252 requires full disclosure of all entities and
organizations receiving Federal funds including awards, contracts, loans, other assistance, and
payments through a single publicly accessible Web site, http://www.USASpending.gov.
Compliance with this law is primarily the responsibility of the Federal agency. However, two
elements of the law require information to be collected and reported by applicants: 1)
information on executive compensation when not already reported through the SAM, and 2)
similar information on all sub-awards/subcontracts/consortiums over $25,000.
For the full text of the requirements under the FFATA and HHS guidelines, go to:


https://www.gpo.gov/fdsys/pkg/PLAW-109publ282/pdf/PLAW-109publ282.pdf,



https://www. fsrs.gov/documents /ffata_legislation_ 110_252.pdf



http://www.hhs.gov/grants/grants/grants-policies-regulations/index.html#FFATA.

5. Reporting of Foreign Taxes (International/Foreign projects only)
A. Valued Added Tax (VAT) and Customs Duties – Customs and import duties, consular fees,
customs surtax, valued added taxes, and other related charges are hereby authorized as an
allowable cost for costs incurred for non-host governmental entities operating where no
applicable tax exemption exists. This waiver does not apply to countries where a bilateral
agreement (or similar legal document) is already in place providing applicable tax exemptions
and it is not applicable to Ministries of Health. Successful applicants will receive information on
VAT requirements via their Notice of Award.
B. The U.S. Department of State requires that agencies collect and report information on the
amount of taxes assessed, reimbursed and not reimbursed by a foreign government against
commodities financed with funds appropriated by the U.S. Department of State, Foreign
Operations and Related Programs Appropriations Act (SFOAA) (“United States foreign
assistance funds”). Outlined below are the specifics of this requirement:
1) Annual Report: The recipient must submit a report on or before November 16 for each foreign
country on the amount of foreign taxes charged, as of September 30 of the same year, by a
foreign government on commodity purchase transactions valued at 500 USD or more financed
with United States foreign assistance funds under this grant during the prior United States fiscal
year (October 1 – September 30), and the amount reimbursed and unreimbursed by the foreign
government. [Reports are required even if the recipient did not pay any taxes during the reporting
period.]
2) Quarterly Report: The recipient must quarterly submit a report on the amount of foreign taxes
charged by a foreign government on commodity purchase transactions valued at 500 USD or
more financed with United States foreign assistance funds under this grant. This report shall be
submitted no later than two weeks following the end of each quarter: April 15, July 15, October
15 and January 15.
3) Terms: For purposes of this clause:
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“Commodity” means any material, article, supplies, goods, or equipment;
“Foreign government” includes any foreign government entity;
“Foreign taxes” means value-added taxes and custom duties assessed by a foreign government
on a commodity. It does not include foreign sales taxes.
4) Where: Submit the reports to the Director and Deputy Director of the CDC office in the
country(ies) in which you are carrying out the activities associated with this cooperative
agreement. In countries where there is no CDC office, send reports to [email protected].
5) Contents of Reports: The reports must contain:
a. recipient name;
b. contact name with phone, fax, and e-mail;
c. agreement number(s) if reporting by agreement(s);
d. reporting period;
e. amount of foreign taxes assessed by each foreign government;
f. amount of any foreign taxes reimbursed by each foreign government;
g. amount of foreign taxes unreimbursed by each foreign government.
6) Subagreements. The recipient must include this reporting requirement in all applicable
subgrants and other subagreements.
6. Termination
CDC may impose other enforcement actions in accordance with 45 CFR 75.371- Remedies for
Noncompliance, as appropriate.
The Federal award may be terminated in whole or in part as follows:
(1) By the HHS awarding agency or pass-through entity, if the non-Federal entity fails to comply
with the terms and conditions of the award;
(2) By the HHS awarding agency or pass-through entity for cause;
(3) By the HHS awarding agency or pass-through entity with the consent of the non-Federal
entity, in which case the two parties must agree upon the termination conditions, including the
effective date and, in the case of partial termination, the portion to be terminated; or
(4) By the non-Federal entity upon sending to the HHS awarding agency or pass-through entity
written notification setting forth the reasons for such termination, the effective date, and, in the
case of partial termination, the portion to be terminated. However, if the HHS awarding agency
or pass-through entity determines in the case of partial termination that the reduced or modified
portion of the Federal award or subaward will not accomplish the purposes for which the Federal
award was made, the HHS awarding agency or pass-through entity may terminate the Federal
award in its entirety.
G. Agency Contacts
CDC encourages inquiries concerning this notice of funding opportunity.
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Program Office Contact
For programmatic technical assistance, contact:
First Name:
Rebekah
Last Name:
Buckley
Project Officer
Department of Health and Human Services
Centers for Disease Control and Prevention
Address:
Telephone:
Email:
[email protected]
Grants Staff Contact
For financial, awards management, or budget assistance, contact:
First Name:
Monique
Last Name:
Tatum
Grants Management Specialist
Department of Health and Human Services
Office of Grants Services
Address:
Telephone:
Email:
[email protected]
For assistance with submission difficulties related to www.grants.gov, contact the Contact
Center by phone at 1-800-518-4726.
Hours of Operation: 24 hours a day, 7 days a week, except on federal holidays.
CDC Telecommunications for persons with hearing loss is available at: TTY 1-888-232-6348
H. Other Information
Following is a list of acceptable attachments applicants can upload as PDF files as part of their
application at www.grants.gov. Applicants may not attach documents other than those listed; if
other documents are attached, applications will not be reviewed.


Project Abstract



Project Narrative
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

Budget Narrative



Report on Programmatic, Budgetary and Commitment Overlap



Table of Contents for Entire Submission

For international NOFOs:


SF424



SF424A



Funding Preference Deliverables

Optional attachments, as determined by CDC programs:
Resumes / CVs
Letters of Support
Organization Charts
Indirect Cost Rate, if applicable
Memorandum of Agreement (MOA)
Memorandum of Understanding (MOU)
Bona Fide Agent status documentation, if applicable
I. Glossary
Activities: The actual events or actions that take place as a part of the program.
Administrative and National Policy Requirements, Additional Requirements
(ARs): Administrative requirements found in 45 CFR Part 75 and other requirements mandated
by statute or CDC policy. All ARs are listed in the Template for CDC programs. CDC programs
must indicate which ARs are relevant to the NOFO; recipients must comply with the ARs listed
in the NOFO. To view brief descriptions of relevant provisions,
see .https://www.cdc.gov/grants/additional-requirements/index.html. Note that 2 CFR 200
supersedes the administrative requirements (A-110 & A-102), cost principles (A-21, A-87 & A122) and audit requirements (A-50, A-89 & A-133).
Approved but Unfunded: Approved but unfunded refers to applications recommended for
approval during the objective review process; however, they were not recommended for funding
by the program office and/or the grants management office.
Assistance Listings: A government-wide collection of federal programs, projects, services, and
activities that provide assistance or benefits to the American public.
Assistance Listings Number: A unique number assigned to each program and NOFO
throughout its lifecycle that enables data and funding tracking and transparency
Award: Financial assistance that provides support or stimulation to accomplish a public purpose.
Awards include grants and other agreements (e.g., cooperative agreements) in the form of
money, or property in lieu of money, by the federal government to an eligible applicant.
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Budget Period or Budget Year: The duration of each individual funding period within the
project period. Traditionally, budget periods are 12 months or 1 year.
Carryover: Unobligated federal funds remaining at the end of any budget period that, with the
approval of the GMO or under an automatic authority, may be carried over to another budget
period to cover allowable costs of that budget period either as an offset or additional
authorization. Obligated but liquidated funds are not considered carryover.
Competing Continuation Award: A financial assistance mechanism that adds funds to a grant
and adds one or more budget periods to the previously established period of performance (i.e.,
extends the “life” of the award).
Continuous Quality Improvement: A system that seeks to improve the provision of services
with an emphasis on future results.
Contracts: An award instrument used to acquire (by purchase, lease, or barter) property or
services for the direct benefit or use of the Federal Government.
Cooperative Agreement: A financial assistance award with the same kind of interagency
relationship as a grant except that it provides for substantial involvement by the federal agency
funding the award. Substantial involvement means that the recipient can expect federal
programmatic collaboration or participation in carrying out the effort under the award.
Cost Sharing or Matching: Refers to program costs not borne by the Federal Government but
by the recipients. It may include the value of allowable third-party, in-kind contributions, as well
as expenditures by the recipient.
Direct Assistance: A financial assistance mechanism, which must be specifically authorized by
statute, whereby goods or services are provided to recipients in lieu of cash. DA generally
involves the assignment of federal personnel or the provision of equipment or supplies, such as
vaccines. DA is primarily used to support payroll and travel expenses of CDC employees
assigned to state, tribal, local, and territorial (STLT) health agencies that are recipients of grants
and cooperative agreements. Most legislative authorities that provide financial assistance to
STLT health agencies allow for the use of DA. https://www.cdc.gov/grants/additionalrequirements/index.html.
Evaluation (program evaluation): The systematic collection of information about the activities,
characteristics, and outcomes of programs (which may include interventions, policies, and
specific projects) to make judgments about that program, improve program effectiveness, and/or
inform decisions about future program development.
Evaluation Plan: A written document describing the overall approach that will be used to guide
an evaluation, including why the evaluation is being conducted, how the findings will likely be
used, and the design and data collection sources and methods. The plan specifies what will be
done, how it will be done, who will do it, and when it will be done. The NOFO evaluation plan is
used to describe how the recipient and/or CDC will determine whether activities are
implemented appropriately and outcomes are achieved.
Federal Funding Accountability and Transparency Act of 2006 (FFATA): Requires that
information about federal awards, including awards, contracts, loans, and other assistance and
payments, be available to the public on a single website at www.USAspending.gov.
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Fiscal Year: The year for which budget dollars are allocated annually. The federal fiscal year
starts October 1 and ends September 30.
Grant: A legal instrument used by the federal government to transfer anything of value to a
recipient for public support or stimulation authorized by statute. Financial assistance may be
money or property. The definition does not include a federal procurement subject to the Federal
Acquisition Regulation; technical assistance (which provides services instead of money); or
assistance in the form of revenue sharing, loans, loan guarantees, interest subsidies, insurance, or
direct payments of any kind to a person or persons. The main difference between a grant and a
cooperative agreement is that in a grant there is no anticipated substantial programmatic
involvement by the federal government under the award.
Grants.gov: A "storefront" web portal for electronic data collection (forms and reports) for
federal grant-making agencies at www.grants.gov.
Grants Management Officer (GMO): The individual designated to serve as the HHS official
responsible for the business management aspects of a particular grant(s) or cooperative
agreement(s). The GMO serves as the counterpart to the business officer of the recipient
organization. In this capacity, the GMO is responsible for all business management matters
associated with the review, negotiation, award, and administration of grants and interprets grants
administration policies and provisions. The GMO works closely with the program or project
officer who is responsible for the scientific, technical, and programmatic aspects of the grant.
Grants Management Specialist (GMS): A federal staff member who oversees the business and
other non-programmatic aspects of one or more grants and/or cooperative agreements. These
activities include, but are not limited to, evaluating grant applications for administrative content
and compliance with regulations and guidelines, negotiating grants, providing consultation and
technical assistance to recipients, post-award administration and closing out grants.
Health Disparities: Differences in health outcomes and their determinants among segments of
the population as defined by social, demographic, environmental, or geographic category.
Health Equity: Striving for the highest possible standard of health for all people and giving
special attention to the needs of those at greatest risk of poor health, based on social conditions.
Health Inequities: Systematic, unfair, and avoidable differences in health outcomes and their
determinants between segments of the population, such as by socioeconomic status (SES),
demographics, or geography.
Healthy People 2030: National health objectives aimed at improving the health of all Americans
by encouraging collaboration across sectors, guiding people toward making informed health
decisions, and measuring the effects of prevention activities.
Inclusion: Both the meaningful involvement of a community’s members in all stages of the
program process and the maximum involvement of the target population that the intervention
will benefit. Inclusion ensures that the views, perspectives, and needs of affected communities,
care providers, and key partners are considered.
Indirect Costs: Costs that are incurred for common or joint objectives and not readily and
specifically identifiable with a particular sponsored project, program, or activity; nevertheless,
these costs are necessary to the operations of the organization. For example, the costs of
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operating and maintaining facilities, depreciation, and administrative salaries generally are
considered indirect costs.
Letter of Intent (LOI): A preliminary, non-binding indication of an organization’s intent to
submit an application.
Lobbying: Direct lobbying includes any attempt to influence legislation, appropriations,
regulations, administrative actions, executive orders (legislation or other orders), or other similar
deliberations at any level of government through communication that directly expresses a view
on proposed or pending legislation or other orders, and which is directed to staff members or
other employees of a legislative body, government officials, or employees who participate in
formulating legislation or other orders. Grass roots lobbying includes efforts directed at inducing
or encouraging members of the public to contact their elected representatives at the federal, state,
or local levels to urge support of, or opposition to, proposed or pending legislative proposals.
Logic Model: A visual representation showing the sequence of related events connecting the
activities of a program with the programs’ desired outcomes and results.
Maintenance of Effort: A requirement contained in authorizing legislation, or applicable
regulations that a recipient must agree to contribute and maintain a specified level of financial
effort from its own resources or other non-government sources to be eligible to receive federal
grant funds. This requirement is typically given in terms of meeting a previous base-year dollar
amount.
Memorandum of Understanding (MOU) or Memorandum of Agreement
(MOA): Document that describes a bilateral or multilateral agreement between parties
expressing a convergence of will between the parties, indicating an intended common line of
action. It is often used in cases where the parties either do not imply a legal commitment or
cannot create a legally enforceable agreement.
Nonprofit Organization: Any corporation, trust, association, cooperative, or other organization
that is operated primarily for scientific, educational, service, charitable, or similar purposes in the
public interest; is not organized for profit; and uses net proceeds to maintain, improve, or expand
the operations of the organization. Nonprofit organizations include institutions of higher
educations, hospitals, and tribal organizations (that is, Indian entities other than federally
recognized Indian tribal governments).
Notice of Award (NoA): The official document, signed (or the electronic equivalent of
signature) by a Grants Management Officer that: (1) notifies the recipient of the award of a grant;
(2) contains or references all the terms and conditions of the grant and Federal funding limits and
obligations; and (3) provides the documentary basis for recording the obligation of Federal funds
in the HHS accounting system.
Objective Review: A process that involves the thorough and consistent examination of
applications based on an unbiased evaluation of scientific or technical merit or other relevant
aspects of the proposal. The review is intended to provide advice to the persons responsible for
making award decisions.
Outcome: The results of program operations or activities; the effects triggered by the program.
For example, increased knowledge, changed attitudes or beliefs, reduced tobacco use, reduced
morbidity and mortality.
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Performance Measurement: The ongoing monitoring and reporting of program
accomplishments, particularly progress toward pre-established goals, typically conducted by
program or agency management. Performance measurement may address the type or level of
program activities conducted (process), the direct products and services delivered by a program
(outputs), or the results of those products and services (outcomes). A “program” may be any
activity, project, function, or policy that has an identifiable purpose or set of objectives.
Period of performance –formerly known as the project period - : The time during which the
recipient may incur obligations to carry out the work authorized under the Federal award. The
start and end dates of the period of performance must be included in the Federal award.
Period of Performance Outcome: An outcome that will occur by the end of the NOFO's
funding period
Plain Writing Act of 2010: The Plain Writing Act of 2010 requires that federal agencies use
clear communication that the public can understand and use. NOFOs must be written in clear,
consistent language so that any reader can understand expectations and intended outcomes of the
funded program. CDC programs should use NOFO plain writing tips when writing NOFOs.
Program Strategies: Strategies are groupings of related activities, usually expressed as general
headers (e.g., Partnerships, Assessment, Policy) or as brief statements (e.g., Form partnerships,
Conduct assessments, Formulate policies).
Program Official: Person responsible for developing the NOFO; can be either a project officer,
program manager, branch chief, division leader, policy official, center leader, or similar staff
member.
Public Health Accreditation Board (PHAB): A nonprofit organization that works to promote
and protect the health of the public by advancing the quality and performance of public health
departments in the U.S. through national public health department
accreditation http://www.phaboard.org.
Social Determinants of Health: Conditions in the environments in which people are born, live,
learn, work, play, worship, and age that affect a wide range of health, functioning, and qualityof-life outcomes and risks.
Statute: An act of the legislature; a particular law enacted and established by the will of the
legislative department of government, expressed with the requisite formalities. In foreign or civil
law any particular municipal law or usage, though resting for its authority on judicial decisions,
or the practice of nations.
Statutory Authority: Authority provided by legal statute that establishes a federal financial
assistance program or award.
System for Award Management (SAM): The primary vendor database for the U.S. federal
government. SAM validates applicant information and electronically shares secure and encrypted
data with federal agencies' finance offices to facilitate paperless payments through Electronic
Funds Transfer (EFT). SAM stores organizational information, allowing www.grants.gov to
verify identity and pre-fill organizational information on grant applications.
Technical Assistance: Advice, assistance, or training pertaining to program development,
implementation, maintenance, or evaluation that is provided by the funding agency.
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UEI: The Unique Entity Identifier (UEI) number is a twelve-digit number assigned by
SAM.gov. When applying for Federal awards or cooperative agreements, all applicant
organizations must obtain a UEI number as the Universal Identifier. UEI number assignment is
free. If an organization does not know its UEI number or needs to register for one, visit
www.sam.gov.
Work Plan: The summary of period of performance outcomes, strategies and activities,
personnel and/or partners who will complete the activities, and the timeline for completion. The
work plan will outline the details of all necessary activities that will be supported through the
approved budget.
NOFO-specific Glossary and Acronyms

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