Grantee Name: DIS: Date of Submittal
Disparity Impact Statement Template
Refer to the Guidance for Preparing a Disparity Impact Statement to complete and submit your disparity impact statement.
Report Header Information (to be prepopulated based on user login credentials)
Project Title
Period of Performance
Budget Period
Reporting Period
Organization Name, PD/PI Name, Phone, Email
Person submitting PPR if not PD/PI on the NOA
Section 1: Health Disparity Population
Health Disparity Population Identification
A population is a health disparity population if there is a significant disparity in the overall rate of disease incidence, prevalence, morbidity, mortality, or survival rates in the population as compared to the health status of the general population.” Minority Health and Health Disparities Research and Education Act United States Public Law 106-525 (2000), p. 2498
According to your approved application, identify the health disparity population within the population(s) of focus identified in your application. For each health disparity population, select the box to indicate the health disparity population [Options will be included in a drop down menu].
Specify the data source (e. g. website link) for determining the health disparity population(s): [Options will be included in a drop down menu e.g. census data]
Referent Group (Required)
Identify the referent or comparison group, used to assess the level of difference in access, use, and outcomes and determine the health disparity population(s): [Options will be included in a drop down menu].
Justification
Identify the social determinants of health to justify the determination of the health disparity population(s). [Options will be included in a drop down menu].
Health Disparity Population Engagement Goal
According to your approved application, indicate the anticipated engagement of the health disparity population in project activities: [Options will be included in a drop down menu].
Disparate Population(s) |
Year 1 |
Year 2 |
Year 3 |
Year 4 |
Year 5 |
Total |
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Section 2: Quality Improvement
Quality improvement and performance monitoring
Indicate how the access, use and outcomes of project activities will be monitored for the:
Health disparity population
Broader population of focus
Will project performance data be used to monitor implementation activities? Y/N
If Y, describe
Will the access to project activities by health disparity populations be monitored? Y/N
If Y, describe
Will the level and quality of activities available through the project across population(s)? Y/N
If Y, describe
Section 3: National CLAS Standards
Adherence to the National CLAS Standards
Will the Quality Improvement Process include the use of the National CLAS Standards? Y/N
If Y, describe
Revised 03.11.24
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Grantee Name: DIS: Date of Submittal |
| Author | Bermudez, Karen (HHS/OASH) |
| File Modified | 0000-00-00 |
| File Created | 2024-12-10 |