**State-based Examples of Network Innovation, Opportunity, and
Replication**

**(SENIOR) Grants**

**REQUEST FOR APPLICATIONS**

*Applications due: November 23, 2004*

A.  **Purpose**

> The Association of State and Territorial Chronic Disease Program
> Directors (CDD), with support from the Centers for Disease Control and
> Prevention (CDC) and the Administration on Aging (AOA), and in
> collaboration with the National Association of State Units on Aging
> (NASUA), announce the availability of funds to implement
> evidence-based health promotion/disease prevention projects for older
> adults at the state and/or local level. Projects will be designed to
> address one of four health promotion areas: 1) expanding the use of
> clinical preventive services; 2) increasing regular physical activity;
> 3) expanding the use of chronic disease self-management techniques; or
> 4) assessing and promoting oral health. Funded projects will draw upon
> the respective strengths, expertise, and resources of both the public
> health and aging services networks.
>
> Information regarding the health promotion areas is included in
> Attachment 1. Applicants are encouraged, although not required, to
> select one of the examples provided (excluding oral health, which has
> a different format explained in Attachment 1.) If an applicant applies
> for funding in one of the first three health promotion topic areas and
> does not choose to use one of the examples found in Attachment 1,
> documentation including references must be provided to demonstrate the
> evidence base for the project selected. Applicants should **not**
> propose to conduct research to investigate unproven projects.

B.  **Eligible Applicants**

> State health departments (SHDs) and state units on aging (SUAs) are
> eligible to apply individually or jointly; active SHD/SUA
> collaboration is a requirement in either instance. Multiple
> applications per state will be accepted for review, but no more than
> one application per state will be funded.

C.  **Funding**

    1.  [Availability of funds:]{.underline} Approximately \$130,000 is
        available in FY 2005 to fund 8-10 awards to address one of the
        following three topic areas: 1) clinical preventive services; 2)
        physical activity; and 3) chronic disease self management.
        Approximately \$50,000 is available in FY 2005 to fund 3-4
        awards to address the topic area of oral health.

> Attachment 1 describes potential projects for each of these topic
> areas. The average award is expected to be \$14,000, with a range from
> \$12,000 to \$16,000. Awards will be made for a project period of 12
> months. Applicants will be notified of award decisions by December 20,
> 2004.

2.  [Use of funds:]{.underline} States may use a fiscal agent. Funds
    available under this announcement may be used for staff salaries,
    local travel, and costs associated with implementing a new project.
    Funds may not be used to supplant funds for existing projects; to
    conduct research; to purchase food, beverages, or equipment; to
    subsidize renovations; or to conduct lobbying activities.

3.  [Recipient financial participation:]{.underline} Matching funds from
    eligible applicants and external partners are not required. However,
    in-kind contributions of staff time and other resources from
    partnering projects are expected. Applicants are encouraged to
    identify and leverage opportunities that will enhance the impact of
    their work. These may include cost-sharing to support shared staff
    positions, donation of supplies and other resources, and other
    activities that are directly related to the project.

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D.  **Application Content**

> 1\. [Cover Page]{.underline} (one page, see Attachment 2 for template)

a.  Applicant name(s)

b.  Contact names and information (including e-mail address and fax
    number) for each applying agency and state collaborator

c.  Total dollar amount requested

d.  Topic area to be addressed: clinical preventive services; physical
    activity; disease self-management; or oral health.

e.  Project title

f.  Project objectives (maximum 40 words)

g.  Abstract project description (maximum 120 words)

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1.  [Narrative Description]{.underline} (max. eight double-spaced pages,
    Times New Roman, 12-point font and one-inch margins)

    a.  Background and Need

        i.  Document the need for the proposed project. Include
            appropriate data when available.

        ii. Describe the challenges and opportunities for implementing
            the proposed project; including those related to
            infrastructure, collaboration, resources, etc.

    b.  Partnerships and Proven Capacity

        i.  Describe briefly the history of collaboration between the
            public health and aging services networks at the state
            level.

        ii. Describe the specific roles of the state unit on aging and
            the state health department.

        iii. Describe the specific roles, partnerships, and capacities
             of other collaborators.

    c.  Project Objectives and Work Plan

        i.  State the objectives of the proposed project. Objectives
            should be measurable and time phased.

        ii. Describe the priority populations that the proposed project
            will target.

        iii. Provide a detailed work plan that describes project
             activities and how they will be conducted (should be
             consistent with Activity Matrix described below).

        iv. **If proposing a project in topic areas 1-3 (clinical
            preventive services, physical activity, chronic disease
            self-management):**

-   If proposing to implement one of the example projects suggested in
    Attachment 1, demonstrate how this program will benefit the
    population of interest and clearly demonstrate in the work plan and
    activity matrix the principal elements of the chosen intervention
    (e.g. training requirements, travel costs, marketing,
    materials/supplies, etc.)

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-   

-   If proposing to implement a project other than those described in
    Attachment 1, describe the evidence base (i.e. describe the science
    behind the intervention and explain why the project is effective),
    including references from the literature. Clearly demonstrate in the
    work plan and activity matrix the principal elements of the chosen
    intervention (e.g. training requirements, travel costs, marketing,
    materials/supplies, etc.)

    i.  **If proposing an oral health project**, please refer to the
        project guidelines in Attachment 1. Activities should include
        Phase I: Assessment; Phase II: Analysis; and Phase III:
        Intervention.

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    a.  Monitoring and Evaluation

        i.  Describe how progress and achievement of objectives will be
            monitored and assessed, and who will monitor progress.

        ii. Describe how information will be collected, analyzed,
            reported/disseminated, and used to ensure fidelity to
            evidence based projects as appropriate.

    b.  Personnel and Management Plan

Describe how the project will be managed, including:

i.  [Staffing]{.underline}: Project staffing, including key staff from
    partner organizations and a project lead from the lead state
    agency(ies).

ii. [Management Plan]{.underline}: Provide a clear description of direct
    lines of authority for project staff.

> 3\. [Appendices]{.underline} (14 page maximum)

a)  Activity Matrix (3 page maximum)

> Describe activities for each objective and identify responsibility,
> key partners, and time frame for completion (see Attachment 3 for
> template)

b)  Budget and Narrative Justification

    i.  [Line-item Budget (1 page maximum):]{.underline} Provide a
        detailed line-item budget for all operating expenses, in-kind
        contributions, and indirect costs.

    ii. [Budget Narrative (2 page maximum):]{.underline} Provide a
        detailed narrative to accompany the line-item budget that
        clearly relates each expense to project activities.

c)  Letters of Support

> Letters must specify role, expectations, and level of commitment
> including in-kind support, if relevant. Must be signed and created on
> letterhead.

i.  Chronic Disease Voting Member

ii. State unit aging Director or Health Promotion Director

iii. State Dental Director (if the proposed project is focused on oral
     health)

iv. Other partners

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d)  Bio-sketches

> Provide abbreviated (250 word maximum per staff member) bio-sketches
> for lead staff at the state level and partner organizations, including
> relevant experience and responsibilities.

e)  Other supporting information

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E.  **Submission Process**

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1.  [Letter of intent:]{.underline} An electronic letter of intent must
    be submitted to Jeanne Alongi, MPH, Consultant to CDD, at
    <alongi@chronicdisease.org> no later than 5:00 pm eastern time
    **October 20, 2004**. The body of the e-mail should indicate the
    name of the applicant agency(ies), the topic area to be addressed
    (clinical preventive services, physical activity, chronic disease
    self-management, or oral health), and an application point of
    contact including phone number and email address. No attachments are
    necessary.

2.  [Application:]{.underline} The application must be submitted
    electronically to Jeanne Alongi, MPH at <alongi@chronicdisease.org>
    no later than 5:00 pm eastern time **November 23, 2004**. No hard
    copies or faxes will be accepted.

    F.  **Minimum Requirements**

        1.  Application materials will be accepted in the order
            received. Items in excess of word and/or page limits will
            not be reviewed.

        2.  Materials will not be accepted late.

        3.  All application materials, including appendices, must be
            submitted electronically. Hard copy and fax materials will
            not be accepted.

        4.  The lead agency(ies) must be an SHD and/or an SUA.

        5.  A contact person for both the SHD and the SUA must be
            identified on the cover sheet regardless of lead agency
            designation.

        6.  Letters of support must be signed and created on letterhead.

        7.  Projects must address one of the four designated health
            promotion topic areas.

    G.  **Technical Assistance opportunities:**

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1.  A technical assistance conference call is scheduled for **October
    13, 2004 from 3:30 -- 5:00pm Eastern. Please call toll-free
    888-576-9873, conference code 37947**. Because only 100 lines have
    been reserved, please consider coordinating with your partners to
    call from one line. During this call, questions will be answered
    regarding the application requirements, topic areas, and grantee
    responsibilities.

2.  Technical assistance in creating an electronic version of hard copy
    documents is available between 10/20 and 11/15 by request to Jeanne
    Alongi at telephone 916-452-2440.

3.  A preliminary check of minimum requirements is available by request
    to Jeanne Alongi at telephone 916-452-2440 between 10/20 and 11/17.
    This check will only include minimum requirements and will not make
    any judgment on anything else including proposal quality,
    competitiveness, evidence-base, etc.

    H.  **Technical Review**

        1.  [Background and Need (15%):]{.underline} The extent to which
            the challenges and opportunities for implementing the
            proposed intervention are described. The extent to which the
            proposed project addresses the identified need in the target
            population.

        2.  [Partnerships and Proven Capacity (20%):]{.underline} The
            extent to which evidence is presented to demonstrate the
            capacity for the state public health and aging agencies to
            successfully work together to implement the proposed
            project. The extent to which the participation and role of
            partners is reflected in letters of support. The extent to
            which specific roles for the SHD, SUA, and appropriate
            partners are described.

        3.  [Objectives and Work Plan (40%):]{.underline} The extent to
            which the proposed project is conforms to the guidelines
            presented for each of the topic areas. The extent to which
            the work plan and timeline present evidence that the
            proposed project can be accomplished and that there is a
            clear connection between activities, objectives, and
            outcomes. The extent to which the proposal demonstrates a
            clear understanding of the components of project
            implementation.

        4.  [Assessment (10%):]{.underline} The extent to which the
            assessment plan is likely to provide meaningful information
            about the achievement of the project goals and objectives
            and assurance of fidelity and expected impact. The extent to
            which the application describes the appropriate use of the
            information collected.

        5.  [Personnel and Management Plan (15%):]{.underline} The
            extent to which the personnel and management plan describes
            how the project will be administered. The extent to which
            the plan describes an organizational structure capable of
            supporting cross-program collaborations necessary to
            developing and implementing the proposed project.

        6.  [Budget and Narrative Justification (not
            scored):]{.underline} The extent to which the proposed
            budget is adequately justified, reasonable, and consistent
            with this announcement and the work plan.

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    I.  **Other Requirements**

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1.  [Progress Reports]{.underline}: The semi-annual progress report will
    be due **July 20, 2005**, and the final progress report will be due
    60 days after the end of the project period. Report format will be
    provided at a later date.

2.  [Financial Status Reports]{.underline}: Funded applicants will be
    required to complete a financial status report that will be due 60
    days after the end of the project period. Report format will be
    provided at a later date.

    J.  **For further information**

> Contact Jeanne Alongi, MPH, consultant to CDC at
> <alongi@chronicdisease.org> or 916-452-2440.

**Attachment 1**

**Examples of** **evidence-based projects and oral health promotion
project guidelines**

**TOPIC AREAS:**

**Topic Area 1: Clinical Preventive Services**

**Topic Area 2: Physical Activity**

**Topic Area 3: Chronic Disease Self-Management**

**Topic Area 4: Oral Health**

**Topic Area 1: Clinical Preventive Services**

Despite the availability of effective clinical preventive services and
the fact that their cost is covered by Medicare, many older adults do
not receive these potentially life-saving services. For example,
nationally 34% of older adults have not received the influenza vaccine
as recommended. By bundling together the delivery of two or more
clinical preventive services in a community setting, it is possible to
increase the efficiency and breadth of their delivery. SPARC (Sickness
Prevention Achieved through Regional Collaboration), a nonprofit health
organization serving four counties at the junction of CT, MA, and NY,
has pioneered this type of work. Examples of successfully piloted
projects of this kind include:

*[Flu Shots and Pneumococcal Vaccines]{.underline}*

Many communities have offered flu shots and pneumococcal immunizations
in the same setting, such as at senior centers, community centers, or
churches. Both shots can be given to seniors at the same visit. The
combination of these vaccinations is highly cost effective and leads to
substantial health benefits. Working with local public health providers,
such as a visiting nurse association or a public health department, it
is also possible to design outreach materials that promote both vaccines
and provide elders with answers to frequently asked questions.

*[Breast Cancer Screening and Adult Immunizations]{.underline}*

Annual influenza clinics are a very efficient setting in which to
promote breast cancer screening among older women. Women age 50 and
older attending a flu shot clinic can be offered the option of receiving
an appointment call from a collaborating radiology facility of her
choice. The results of the mammogram would be sent to patient's medical
home. Flu clinics attract women across a broad racial, ethnic, and
socio-economic range, because the economic barriers to receiving flu
shots are minimal. Moreover, because the recommended interval both
between flu shots and screening mammograms is twelve months, combining
these two clinical preventive services creates an opportunity to boost
the use of a service with lower utilization rates (mammograms) through
its link with a service with higher rates (flu shots).

*[Cholesterol Screening and Adult Immunizations]{.underline}*

Cholesterol screening, pneumococcal immunization, and tetanus booster
can be provided throughout the year in community settings. After-church
clinics, which would be open to congregations and the public-at-large,
are a good setting at which to attract elders. Initiatives of this kind
represent a good opportunity to bring together elder services, community
leaders, and local health departments to coordinate and promote disease
prevention activities. Announcements can be placed in church bulletins,
on local cable TV, in community calendars, and in newspapers serving the
community.

*[Preventive Services and Home Delivered Meals]{.underline}*

Among the most vulnerable elder residents are those who are unable to
leave their homes. It is possible to survey home delivered meals
recipients to identify individuals in need of preventive services,
including flu shots, pneumonia shots, and cholesterol screening. Funding
can be used to hire nurses to provide or facilitate these immunization
and screening measures to senior clients.

For general information about the SPARC program, visit
[www.sparc-health.org](http://www.sparc-health.org/).

***References:***

Christenson B, Lundbergh P, Hedland J, Ortqvist A. Effects of a
large-scale intervention with influenza and 23-valent pneumococcal
vaccines in adults aged 65 years and older: a prospective study. Lancet
2001;357:1008-11.

Shenson D, Cassarino L, DiMartino L, Marantz P, Bolen J, Good B,
Alderman M, Improving Access to Mammography Through Community-based
Influenza Clinics: A Quasi-Experimental Study. *Am J Prev Med*. 
2001;20(2):97-102

Weaver M, Krieger J, Castorina J, Walls M, Ciske S. Cost-effectiveness
of combined outreach for pneumococcal and influenza vaccines. Arch
Intern Med. 2001;161:111-20.

**Topic Area 2: Physical Activity**

*[PACE: People with Arthritis Can Exercise]{.underline}*

PACE is an exercise program designed specifically for people with
arthritis that uses gentle activities to help increase joint flexibility
and range of motion and to help maintain muscle strength. Two levels of
PACE are available, basic and advanced, to address the varying levels of
fitness and limitation among those with arthritis. PACE participants
have experienced such benefits as increased functional ability,
increased self-care behaviors, decreased pain, and decreased depression.

To implement this course it is necessary to identify and access leaders
in your local area who are appropriately trained to deliver the course.
Contact the Arthritis Program Director at the SHD (for listing of
Directors by state, go to
[www.chronicdisease.org](http://www.chronicdisease.org/), click on
"Membership Directory", and find your state), or the state/local
Arthritis Foundation Chapter (for a listing of chapters, visit
[www.arthritis.org](http://www.arthritis.org/)) for help in identifying
trained leaders.

***Reference:***

Brady TJ, Kruger J, Helmick CG, Callahan LF, Boutaugh ML. Intervention
programs for arthritis and other rheumatic diseases. Health Education
and Behavior 2003;30(1):44-63.

*[Senior Wellness Lifetime Fitness Program]{.underline}*

The Lifetime Fitness Program is an exercise program for seniors which
offers low-cost fitness classes taught by certified fitness instructors.
The one-hour classes meet three times per week in ongoing, five-week
sessions. The classes include strength training with wrist and ankle
weights, as well as aerobics, stretching, and balancing exercises. The
program is designed to be safe and effective for seniors with a wide
range of physical abilities. This program began as a partnership between
Senior Services of Seattle/King County, Group Health Cooperative of
Puget Sound, and the University of Washington Health Promotion Research
Center. Studies have shown a marked improvement in participants\'
physical and social functioning, as well as a decline in areas such as
pain, fatigue, and depression. To replicate this program, visit their
website:
[http://www.seniorservices.org/wellness/replication.htm#LifetimeFitnessProgram]{.underline}.

***Reference:***

Wallace, J. I. et al. (1998). Implementation and effectiveness of a
community-based health promotion program for older adults. *Journal of
Gerontology: Medical Science*s, 53a(4): M301-M306. URL:
[www.americangeriatrics.org]{.underline}

**Topic Area 3: Chronic Disease Self-Management**

*[Chronic Disease Self-Management Program]{.underline}*

The Chronic Disease Self-Management Program is a 7-week, small-group
intervention attended by people with different chronic conditions. It is
taught largely by peer instructors from a highly structured manual. The
program is based on self-efficacy theory and emphasizes problem solving,
decision making, and confidence building. At one year, participants in
the program experienced statistically significant improvements in health
behaviors (exercise, cognitive symptom management, and communication
with physicians), self-efficacy, and health status (fatigue, shortness
of breath, pain, role function, depression, and health distress) and had
fewer visits to the emergency department. There were slightly fewer
outpatient visits to physicians and fewer days in hospital, but the
differences were not statistically significant. Program costs were
estimated to be about \$200 per participant.

To implement this course, it is necessary to find organizations licensed
to offer the program. Please visit
<http://patienteducation.stanford.edu/programs/> for a listing of these
organizations by state. A listing of Spanish-language organizations is
also available through this website.

***Reference:***

Lorig, K. R. *et al*. (1999). Evidence suggesting that a chronic disease
self-management program can improve health status while reducing
hospitalization. *Medical Care*, *37*(1): 5-14. URL:
[www.1ww-medicalcare.com]{.underline}

*[The Arthritis Self-Help Course]{.underline}*

The Arthritis Self-Help Course (ASHC) is a 6-week group education course
that teaches people how to manage their arthritis and lessen its
effects. Participants learn new pain management techniques, how to deal
with fatigue and stress more effectively, how to develop an
individualized exercise program, the roles of medication, and other
helpful skills that increase their ability to live with their arthritis.
Among people who have completed the course, arthritis pain declined by
20% and costly physician visits were reduced by 40%.

To implement this course it is necessary to identify and access leaders
in your local area who are appropriately trained to deliver the course.
Contact the Arthritis Program Director at the SHD (for listing of
Directors by state, go to
[www.chronicdisease.org](http://www.chronicdisease.org/), click on
"Membership Directory," and find your state), or the state/local
Arthritis Foundation Chapter (for a listing of chapters, visit
[www.arthritis.org](http://www.arthritis.org/)) for help in identifying
trained leaders.

***Reference:***

Brady TJ, Kruger J, Helmick CG, Callahan LF, Boutaugh ML. Intervention
programs for arthritis and other rheumatic diseases. Health Education
and Behavior 2003;30(1):44-63.

**Topic Area 4: Oral Health**

Older adults today are keeping more of their natural teeth. Although
this is good news -- evidence suggests that total tooth loss in adults
has been linked to malnutrition, weight loss, and poorer overall
health - it also offers new challenges. Older adults who have their
natural teeth may be at higher risk for tooth decay and may have less
access to dental care for several reasons. For example, older adults are
less likely to have dental insurance. Additionally, they may suffer from
conditions that decrease mobility and make it difficult to travel to the
dentist's office. As a result, national studies show that older adults
have more untreated tooth decay than any other age group, which in turn
may lead to pain and suffering and ultimately to problems in eating,
speaking, and social interaction (people with oral condition may avoid
conversation or laughing, smiling or other non-verbal expressions that
show their mouth or teeth.)

There is much about the oral health status of older Americans that is
not well understood, especially among the institutionalized and
home-bound. Although studies have shown that fluoride delivered through
community drinking water, toothpaste, mouth rinses, or topical
application is effective in preventing decay among older adults, little
is known about how frequently these prevention interventions are used or
if health and mobility issues preclude their use among certain older
adults. Better knowledge about the oral health status of older adults
and their current usage of interventions to prevent dental decay would
enable the Division of Oral Health at CDC to more effectively design and
deliver community-based dental public health programs for older adults.

**Phase 1** of the project will focus on **assessment** of the oral
health status of older Americans. Validated questions that applicants
should use as a basis to assess oral health knowledge, behaviors,
status, and access to care of older adults are provided below.
Applicants are **required** to use questions 1-9 in the proposed
assessment, and encouraged to use questions 10-12.

Potential settings for assessment include home settings (e.g., home
delivered meal programs, home health services, faith-based home visit
programs, community programs that visit homebound older adults);
congregate meal sites; senior center programs (e.g., physical activity,
bingo, gardening); and senior housing sites.

The collection of dental health information among the elderly will help
participating states 1) identify unmet dental health needs, 2) identify
priority populations for delivery of dental disease prevention projects,
3) identify community strategies to address these needs, and 4)
encourage partnerships among stakeholders involved in aging, public
health, and dental public health and dentistry.

**Phase 2** of the project will focus on **analysis** of data. This is
intended to be a descriptive report that provides simple summary
statistics to identify priority populations, priority settings, and
needs or gaps in prevention or treatment activities.

**Phase 3** of the project will focus on **interventions**, with special
emphasis on prevention of dental disease. At this time CDC has not
developed evidence-based programs for older adults, and is looking to
states to generate creative solutions and interventions that will
provide future directions. Opportunities related to this phase include
the distribution of primary prevention aids, such as dental products
containing fluoride and educational materials; referral mechanisms that
will provide contacts with free or reduced cost dental care in the
community; and partnerships with multiple stakeholders including the
state oral health director, state oral health coalition, clinical dental
community, dental manufacturers, health insurance industry, and schools
of dentistry.

For more information on this project, representatives from the CDC
Division of Oral Health will be available during the technical
assistance call described above in section G.1.

***References:***

U.S. Department of Health and Human Services (2000). Oral health in
America*:* a report of the Surgeon General. Rockville, MD: U.S.
Department of Health and Human Services, National Institute of Dental
and Craniofacial Research, National Institutes of Health.

Hand JS, Hunt RJ, Beck JD. Incidence of coronal and root caries in an
older adult population. J Public Health Dent 1988; 48:14-19.

Gilbert GH, Foerster U, Dolan TA, Duncan RP, Ringelberg ML. Twenty-four
month coronal caries incidence: the role of dental care and race*.*
Caries Res 2000; 34: 367-79.

Kaste L, Selwitz R, Oldakowski R. Coronal caries in primary and
permanent dentition of children and adolescents, 1 to 17 years of age:
U.S., 1988-1991*.* J Dent Res 1996; 75:631-41.

Winn DM, Brunelle JA, Selwitz RH, Kaste LM. Coronal and root caries in
the dentition of adults in the United States, 1988-1991*.* J Dent Res
1996; 75: 642-51.

**Oral Health Data Assessment Questions**

*Questions 1-9 are* ***required*** *for the assessment, and questions
10-12 are encouraged, but not required.*

> OA1: How often do you brush your teeth?

1.  Never

2.  Once a month

3.  A few times a month

4.  Once a week

5.  A few times a week

6.  Once a day

7.  Twice a day

> 9\. Refused

10. Don't know

> OA2: How many of your permanent teeth have been removed because of
> tooth decay or gum disease? Do not include teeth lost for other
> reasons, such as injury or orthodontics.

1.  1 to 5

2.  6 or more but not all

3.  All

4.  None

> 9\. Refused
>
> 10\. Don't know
>
> OA3: Apart from fluoride toothpaste, do you use fluoride in any other
> way, that is in mouthwashes or tablets?

1.  Yes

2.  No

> 9\. Refused
>
> 10\. Don't know
>
> OA4: By yourself and without using any special equipment, how much
> difficulty do you have using your fingers to grasp or handle small
> objects?

1.  No difficulty

2.  Some Difficulty

3.  Much Difficulty

4.  Unable to do

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9.  Refused

10. Don't know

> OA5: About how long has it been since you last visited a dentist?
> Include all kinds of dentists, such as oral surgeons and all other
> dental specialists, as well as dental hygienists.

1.  6 months or less

2.  More than 6 months, but not more than 1 year ago

3.  More than 1 year, but not more than 2 years ago

4.  More than 2 years, but not more than 3 years ago

5.  More than 3 years, but not more than 5 years ago

6.  Never have been

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9.  Refused

10. Don't know

> OA6: If applicable, what is the main reason you have [not]{.underline}
> visited the dentist in the past year?

1.  Fear, apprehension, nervousness, pain, dislike going

2.  Cost

3.  Do not have/know a dentist

4.  Cannot get to the office/clinic (too far away, no transportation, no
    appointments available)

    1.  No reason to go (no problems, no teeth)

    2.  Other priorities

    3.  Have not thought of it

    4.  Not applicable, have gone to dentist within the last year

    5.  Refused

    6.  Don't know

> OA7: What was the main reason you last visited a dentist?

1.  Went in on own for check-up, examination, or cleaning

2.  Was called by the dentist for check-up, examination or cleaning

3.  Something was wrong, bothering or hurting me

4.  Went for treatment of a condition that dentist discovered at earlier
    check-up or examination

5.  Other

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9.  Refused

10. Don't know

> OA8: How often do you limit the kinds or amounts of food you eat
> because of problems with your teeth or dentures?

1.  Always

2.  Very Often

3.  Often

4.  Sometimes

5.  Seldom

6.  Never

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9.  Refused

> 10\. Don't know
>
> OA9: What kind of dental care do you need now?

1.  Teeth filled or replaced (for example, fillings, crowns, or bridges)

2.  Teeth pulled

3.  Gum treatment

4.  Denture work

5.  Relief of pain

6.  Other

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9.  Refused

10. Don't know

> OA10: Do you have difficulties swallowing any foods?

1.  Yes

2.  No

> 9\. Refused

10. Don't know

> OA11: Is there a particular dentist or dental clinic that you usually
> go to if you need dental care or dental advice?

1.  Yes

2.  No

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9.  Refused

10. Don't know

> OA12: Do you have any kind of insurance coverage that pays for some or
> all of your routine dental care, including dental insurance, prepaid
> plans such as HMOs, or government plans such as Medicaid?

1.  Yes

2.  No

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9.  Refused

10. Don't know

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8.  
9.  
10. 
11. 
12. 
13. 
14. 

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    1.  
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    26. 

**ATTACHMENT 2**

**SENIOR Grant Application Cover Page**

  ------------- -- ------ -- --------- -- --------- -------- --- ------------- -- -- -----------------------------
  State:                     Project                                                 
                             title:                                                  

  Total amount                            \$        Topic                            Clinical Preventive Services
  requested:                                        area                             
                                                    (check                           
                                                    one):                            

  Lead agency                             SHD                                        Physical Activity
  type (check                                                                        
  one):                                                                              

                                          SUA                                        Chronic Disease
                                                                                     Self-Management

                                          SHD/SUA                                    Oral Health

  Lead                                                                               
  Agency(s)                                                                          
  name:                                                                              

  SHD Contact                                                    SUA Contact         
  information                                                    information         

  Name:                                                          Name:               

  Title:                                                         Title:              

  Agency:                                                        Agency:             

  Address:                                                       Address:            

  Phone:                                                         Phone:              

  Fax:                                                           Fax:                

  Email:                                                         Email:              

  Fiscal agent                                                                       
  (if other                                                                          
  than lead                                                                          
  agency):                                                                           

  Project                                                                            
  objectives                                                                         
  (maximum 40                                                                        
  words):                                                                            

  Description                                                                        
  of project                                                                         
  (maximum 120                                                                       
  words):                                                                            
  ------------- -- ------ -- --------- -- --------- -------- --- ------------- -- -- -----------------------------

<table style="width:100%;">
<colgroup>
<col style="width: 13%" />
<col style="width: 17%" />
<col style="width: 13%" />
<col style="width: 12%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="16"><strong>Attachment 3: Activity Matrix</strong></td>
</tr>
<tr class="even">
<td rowspan="2"></td>
<td rowspan="2"><strong><u>Activity</u></strong></td>
<td rowspan="2"><strong><u>Key Staff Responsible</u></strong></td>
<td rowspan="2"><strong><u>Partners</u></strong></td>
<td colspan="12"><p><strong><u>Time Line</u></strong></p>
<p><em><strong>Month / Year</strong></em></p></td>
</tr>
<tr class="odd">
<td><blockquote>
<p><strong>Jan 05</strong></p>
</blockquote></td>
<td><blockquote>
<p><strong>Feb 05</strong></p>
</blockquote></td>
<td><blockquote>
<p><strong>Mar 05</strong></p>
</blockquote></td>
<td><blockquote>
<p><strong>Apr 05</strong></p>
</blockquote></td>
<td><blockquote>
<p><strong>May 05</strong></p>
</blockquote></td>
<td><blockquote>
<p><strong>June 05</strong></p>
</blockquote></td>
<td><blockquote>
<p><strong>July 05</strong></p>
</blockquote></td>
<td><blockquote>
<p><strong>Aug 05</strong></p>
</blockquote></td>
<td><blockquote>
<p><strong>Sep 05</strong></p>
</blockquote></td>
<td><blockquote>
<p><strong>Oct 05</strong></p>
</blockquote></td>
<td><blockquote>
<p><strong>Nov 05</strong></p>
</blockquote></td>
<td><blockquote>
<p><strong>Dec 05</strong></p>
</blockquote></td>
</tr>
<tr class="even">
<td rowspan="3"><strong><u>Objective 1</u></strong></td>
<td>1.</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>2.</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>3.</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td rowspan="3"><strong><u>Objective 2</u></strong></td>
<td>1.</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>2.</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>3.</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>