**U.S. Department of Health and Human Services**

**Health Resources and Services Administration**

**Maternal and Child Health Bureau**

**Division of Healthy Start and Perinatal Services**

> ***Women's Health***
>
> New Competition
>
> *Announcement No. HRSA-06-063*
>
> *Innovative Approaches to Promoting a Healthy Weight in Women (H59)*
>
> ***Catalog of Federal Domestic Assistance (CFDA)***
>
> ***No. 93.110***

**APPLICATION PROGRAM GUIDANCE**

Fiscal Year 2006

**Application Due Date: December 2, 2005**

**Release Date: September 30, 2005**

**Date of Issuance date: September 30, 2005**

> Contact Name(s): Lisa R. King, MA
>
> Title, Office: Division of Healthy Start and Perinatal Services
>
> Telephone: 301/443-0543
>
> Fax: 301/594-0186
>
> E-Mail(s): <lisa.king@hrsa.hhs.gov>

Authority: Social Security Act, Title V, Section 502 (a) (1)

***This page intentionally left blank***

**Table of Contents**

[**[I. FUNDING OPPORTUNITY DESCRIPTION
6]{.smallcaps}**](#funding-opportunity-description)

[Purpose](#__RefHeading___Toc55379015)

[Background 6](#__RefHeading___Toc55379016)

[Maternal and Child Health Bureau 7](#maternal-and-child-health-bureau)

[II. Award Information 9](#refheading___toc55379018)

Type of
Award........................................................................................................................\...\...\...\...\...9

[**Summary of Funding** 9](#__RefHeading___Toc55379019)

[III.Eligibility Information 9](#__RefHeading___Toc55379020)

[**1. Eligible Applicants** 9](#__RefHeading___Toc55379021)

[**2. Cost Sharing/Matching: Not Required**
9](#__RefHeading___Toc55379022)

[IV. Application and Submission Information
9](#__RefHeading___Toc55379023)

[1. Address to Request Application Package](#__RefHeading___Toc55379024)
9

*Application
Materials*.........................................................................................................\...\...\...\...\.....9

[2. Content and Form of Application
Submission](#content-and-form-of-application-submission) 10

*Application Format
Requirements*..........................................................................................\...\...\...\...\....10

*Application
Format*.....................................................................................................................\...10

[I. Application Face Page](#__RefHeading___Toc55379027) 10 II. Table of
Contents..................................................................................................................\...\...\....12

[III. Application Checklist 12](#__RefHeading___Toc55379030)

[IV. Budget 12](#__RefHeading___Toc55379031)

[V. Budget Justification 12](#__RefHeading___Toc55379032)

[VI. Staffing Plan and Personnel Requirements
14](#__RefHeading___Toc55379033)

[VII. Assurances 14](#__RefHeading___Toc55379034)

[VIII.Certifications 14](#__RefHeading___Toc55379035)

[IX. Project Abstract 14](#__RefHeading___Toc55379036)

[X. Program Narrative 15](#__RefHeading___Toc55379037)

[XI. Program Specific Forms 16](#__RefHeading___Toc55379038)

[XII. Appendices 16](#__RefHeading___Toc55379039)

[3. Submission Dates And Times 17](#submission-dates-and-times)

[4. Intergovernmental Review 18](#__RefHeading___Toc55379041)

[5. Funding Restrictions 18](#application-due-date)

6\. Other Submission
Requirements..........................................................................................\...\...\...\...\...\....19

[V. APPLICATION REVIEW INFORMATION 22](#__RefHeading___Toc55379048)

[A*.*](#__RefHeading___Toc55379048) *Innovative Approaches to Promoting
a Healthy Weight in Women* 22

[1. Review Criteria 23](#__RefHeading___Toc55379053)

[2. Review and Selection Process 27](#review-criteria)

3\. Anticipated Award
Date\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....27

[VI. AWARD ADMINISTRATION INFORMATION 28](#__RefHeading___Toc55379061)

[1. Award Notices 28](#award-notices)

[2. Administrative and National Policy Requirements
28](#administrative-and-national-policy-requirements)

[3. Reporting 31](#__RefHeading___Toc55379071)

[VII. Agency Contacts 33](#__RefHeading___Toc55379072)

**VIII**[. Tips for Writing a Strong Application
34](#__RefHeading___Toc55379073)

[appendix a -- forms and instructions 35](#__RefHeading___Toc55379074)

[appendix b - Performance
measures](#__RefHeading___Toc55379076).............................................................................................................54

[appendix c -- reference list 6](#__RefHeading___Toc55379082)5

[appendix d - state title v director -- maternal and child health (mch)
Director................................................................................................................................................\...66](#__RefHeading___Toc55379085)

[appendix e - u.s. public health service -- Department of Health and
Human Service, office on women\'s health regional women\'s health
coordinators
......................................................................................................73](#__RefHeading___Toc55379086)

**[Appendix f - Department of Health and Human Services, Office of
Population Affairs,]{.smallcaps}**

**[Office of Family Planning, Regional Program
Consultants..........................................................................75]{.smallcaps}**

**Executive Summary**

Under this announcement, the *Innovative Approaches to Promoting a
Healthy Weight in Women (IPHWW)* grant will fund projects to develop
creative, innovative approaches that are effective in reducing the
prevalence of overweight/obesity in women by increasing the number of
women who adopt positive health lifestyles. The interventions must be
substantive in nature and positively impact the women's knowledge,
attitudes, and behaviors. These approaches should target women in
communities who have limited access to preventive health services.

-   Total amount of Funding to be awarded: \$450,000.

-   Number of Grants and project period: three (3) awards for three
    years beginning May 1, 2006.

-   Eligibility: As cited in 42 CFR Part 51a.3 (a), any public or
    private entity, including an Indian tribe or tribal organization (as
    those terms are defined at 25 U.S.C. 450b), faith based and
    community based organization is eligible to apply for this Federal
    funding.

-   Cost sharing does not apply to this grant competition.

# FUNDING OPPORTUNITY DESCRIPTION

## Purpose {#purpose .unnumbered}

> This announcement solicits applications for the *Innovative Approaches
> to Promoting a Healthy Weight in Women* demonstration grant program.
> The purpose of this grant is to develop and demonstrate creative,
> innovative approaches that are effective at reducing the incidence and
> prevalence of overweight and obesity in women by increasing the number
> of women who adopt positive healthy lifestyles.

## Background {#background .unnumbered}

> Increased attention to women=s health and behavioral health issues has
> illuminated the fact that women=s health care is fragmented in its
> delivery, particularly with regard to the separation of reproductive
> and non-reproductive services. Women may have access to reproductive
> health care but not to comprehensive, coordinated care that includes
> preventive services, education and counseling, appropriate referrals
> and follow-up. In particular, many women do not have access to the
> type of Aprimary care@ characterized by first-contact care that is
> comprehensive, coordinated, and based on sustained partnerships
> between provider and patient (Donaldson, Yordy, Lohr, Vanselow, 1996).
> Minority and underserved women are less likely to have health
> insurance and to receive comprehensive and continuous health services.
> In fact, nearly one of three women without health insurance did not
> receive preventive care in the past year, compared with one of seven
> insured women (The Commonwealth Fund, 1999). Yet, these same women
> have the greatest disparities in health status, and therefore, the
> greatest need for such services.
>
> What is the role of women=s health in maternal and child health?
> According to Bennett (1997), AInfant outcomes and child health and
> development are strongly affected by women=s preconceptional health
> status and health behaviors, by nonobstetric as well as obstetric
> aspects of pregnancy, and by women=s general physical and
> psychological well-being in the immediate postpartum period and for
> many years afterward.@ Therefore, broadening the scope of primary care
> for women by adopting a women=s health approach for the MCH population
> could be an efficient means of improving both birth outcomes and
> women=s health status.
>
> A women's health approach is a more comprehensive approach that
> includes (but is not limited to) counseling about diet, well-being,
> nutrition, physical activity; monitoring blood lipid levels, blood
> pressure; and perhaps clinical breast exams. Conceptually, this
> expanded approach to women's health can be described as the
> preservation of wellness and the prevention of illness. This approach
> encourages providers to address the changing needs of the women not
> only during their reproductive years but throughout their life span. A
> women=s health approach also offers MCH the potential to expand
> knowledge and practice in many areas of health promotion and disease
> prevention for women, children, and families.
>
> In many states, Title V programs already provide a variety of services
> for women beyond pregnancy-related care through a variety of
> contracting and grants mechanisms and therefore, are among the logical
> partners to improve systems of care for women in MCH programs.
> Clearly, coordination of women's health services is an important
> priority and an integral part of the
>
> MCHB's overall goal of improving the health of women, infants,
> children, adolescents and their families. Utilization of a holistic
> approach to the development of coordinated systems for women's health,
> that includes mental health, is an important strategy to achieve that
> goal.

## Maternal and Child Health Bureau {#maternal-and-child-health-bureau .unnumbered}

> The Maternal and Child Health Bureau (MCHB) is a component of the
> Health Resources and Services Administration (HRSA) within the
> Department of Health and Human Services (DHHS).
>
> A widely held philosophy in maternal and child health asserts that
> ensuring the highest level of health among women also improves the
> health and wellbeing of children, families, the workforce and the
> nation. Over the past several years, the Maternal and Child Health
> Bureau's (MCHB) Division of Perinatal Systems and Women's Health
> (DPSWH) has increasingly recognized the need to optimize women's
> health through collaborations with multiple Federal agencies and
> public/private organizations and through grant support for a variety
> of demonstration programs focusing on improving women's health.
> Attention has been strategically placed on two major areas: state
> infrastructure development for women's health; and addressing common
> health risk factors for women.
>
> Collaborative activities and partnerships have been forged with key
> organizations, such as the Association of Maternal and Child Health
> Programs (AMCHP), National Centers of Excellence in Women=s Health,
> Community Centers of Excellence in Women's Health, provider
> organizations (e.g., Association of Women=s Health Obstetric and
> Neonatal Nurses, American College of Obstetricians and Gynecologists,
> American College of Nurse Midwives, Nurse Practitioners in Women=s
> Health), private organizations, Federal agencies (e.g., FDA, NIH, CDC,
> HHS Office on Women=s Health), and state and local agencies that are
> vital to promoting a women=s health agenda through the delivery of
> coordinated services and systems, particularly in relation to health
> promotion/risk reduction behaviors.
>
> To date, MCHB has funded 12 states under its Integrated Comprehensive
> Women's Health Services in State MCH Programs initiative. The intent
> of the program is to establish a focal point within the state for
> women's health and to then improve coordination between the many
> women's health-related funding sources, in order to maximize
> coordination and resources. Frequently, without coordination, there is
> duplication of services and at times conflicting messages as to the
> intent of programs serving women. Findings from this initiative
> indicate that it is critical that consumers be a part of planning for
> state women's health efforts.
>
> In addition to building local and state health infrastructure, DPSWH
> programs have focused on specific behavioral risk factors that
> contribute to poor health outcomes in women's health, and affect the
> incidence of heart disease, cancer, and diabetes. Obesity is such a
> risk factor, and one that needs to be targeted by states and
> communities to improve women's health across a broad spectrum of
> health outcomes.
>
> **MCHB Mission Statement:** The mission of the MCHB is to provide
> national leadership in partnership with key stakeholders, to reduce
> disparities, assure the availability of quality care, and strengthen
> the nation's maternal and child health (MCH) infrastructure in order
> to improve the physical and mental health, safety, and well-being of
> the MCH population -- *all* women, infants, children, adolescents and
> their families, including fathers and children with special health
> care needs (CSHCN).
>
> **History and Purpose:** Since its inception, Maternal and Child
> Health (MCH) Services Grants through Title V of the Social Security
> Act have provided a foundation for ensuring the health of our Nation's
> mothers and children. In 1935, through the new Social Security Act,
> the Federal Government, in authorizing Title V, pledged its support of
> State efforts to extend health and welfare services for mothers and
> children.
>
> []{.mark}
>
> **Block and Discretionary Grants:** When the Title V program was
> converted to a block grant in 1981, seven categorical programs were
> consolidated into a single block grant with increased emphasis on
> planning, accountability, and systems development at both the Federal
> and State levels. It also called for increased leadership and
> programmatic responsibilities at the Federal level, especially in the
> area of national policy development and policy coordination.
>
> **Discretionary Grants:** In 1981, Congress authorized funding for
> Special Projects of Regional and National Significance (SPRANS) as
> part of the MCH Block Grant. *Special Projects of Regional and
> National Significance (SPRANS): For SPRANS, fifteen percent of MCH
> Block Grant funds are set aside programs in the* following general
> categories: MCH research; MCH training; Genetic disease testing,
> counseling and information dissemination; Hemophilia diagnostic and
> treatment centers; and other special projects to improve maternal and
> child health. *Community Integrated Services Systems (CISS):* For
> CISS, 12.75 percent of the funding above \$600 million is provided for
> maternal and infant home visiting programs; projects to increase
> participation of obstetricians and pediatricians; Integrated maternal
> and child health service delivery systems; maternal and child health
> centers providing pregnancy services for women and preventive and
> primary care services for infants (up to one year) operating under the
> direction of a not-for-profit hospital; maternal and child projects to
> serve rural populations; and outpatient and community-based services
> programs (including day care services) for children with special
> health care needs, whose medical services are provided primarily
> through inpatient institutional care.
>
> **This grant is funded under the Social Security Act, Title V, Section
> 502 (a) (1).**

[]{#refheading___toc55379018 .anchor}**II. Award Information**

**Type of Award**

Funding will be provided in the form of a grant.

> **Summary of Funding**
>
> The *Innovative Approaches to Promoting a Healthy Weight in Women
> (H59)* grant program will provide funding during Federal fiscal years
> 2006-2008. Approximately \$450,000 is expected to be available yearly
> to fund three (3) grantees over this three-year period. Funding beyond
> the first year is dependent on the availability of appropriated funds,
> satisfactory grantee performance, and a decision that funding is in
> the best interest of the Federal government.

[]{#__RefHeading___Toc55379020 .anchor}**III. Eligibility Information**

[]{#__RefHeading___Toc55379021 .anchor}**1. Eligible Applicants**

> ***SPRANS Grants***: As cited in 42 CFR Part 51a.3 (a), any public or
> private entity, including an Indian tribe or tribal organization (as
> those terms are defined at 25 U.S.C. 450b), faith based and community
> based organization is eligible to apply for this Federal funding.
> Organizations that have [previously received funding]{.underline}
> under the *[Innovative Approaches to Promoting a Healthy Weight in
> Women Demonstration Grant (H59)]{.underline}* initiative are not
> eligible to apply for the same funding again in the interest of
> equitable geographic distribution. Faith-based and community-based
> organizations are eligible to apply for these grants.

[]{#__RefHeading___Toc55379022 .anchor}

**2. Cost Sharing/Matching: Not Required**

[]{#__RefHeading___Toc55379023 .anchor}

**IV. APPLICATION AND SUBMISSION INFORMATION**

##  1. Address to Request Application Package  {#address-to-request-application-package .unnumbered}

**Application Materials**

> Applicants must submit proposals using appropriate form(s) Public
> Health Service (PHS) Application Form 5161-1. This form contains
> additional general information and instructions for grant
> applications, proposal narratives, and budgets. This form may be
> obtained from the following sites by:
>
> []{.mark}

(1) Download from <http://www.hrsa.gov/grants/forms.htm>

> Or

(2) Contacting the HRSA Grants Application Center at:

> The Legin Group, Inc.
>
> 901 Russell Avenue, Suite 450
>
> Gaithersburg, MD 20879
>
> Telephone: 877-477-2123
>
> <HRSAGAC@hrsa.gov>.
>
> Instructions for preparing portions of the application that must
> accompany Application Form 5161-1; appear in the "Application Format"
> section below.

##  2. Content and Form of Application Submission  {#content-and-form-of-application-submission .unnumbered}

**Application Format Requirements**

> If applying on-line, the total size of all uploaded files **may not
> exceed the equivalent of 80 pages when printed by HRSA, approximately
> 10 MB.** **This 80-page limit includes the abstract, project and
> budget narratives, attachments, appendices and letters of commitment
> and support.**
>
> If applying on paper, **the entire application may not exceed 80 pages
> in length.** Pages must be numbered consecutively.
>
> **Applications, whether submitted on paper or electronically, that
> exceed the specified limits (80 pages or approximately 10 MB, or that
> exceed 80 pages when printed by HRSA) will be deemed non-compliant.
> All non-compliant applications will be returned to the applicant
> without further consideration.**

a.  Number of Copies (Paper Applications only)

> []{.mark}
>
> Please submit one (1) original and two (2) unbound copies of the
> application.
>
> Please do not bind or staple the application. Application must be
> single sided.

b.  Font

> []{.mark}
>
> Please use an easily readable serif typeface, such as Times Roman,
> Courier, or CG Times. The text and table portions of the application
> must be submitted in not less than 12 point and 1.0 line spacing.
> Applications not adhering to 12 point font requirements may be
> returned.
>
> []{.mark}
>
> []{.mark}
>
> []{.mark}
>
> []{.mark}

c.  Paper Size and Margins

> For scanning purposes, please submit the application on 8 ½" x 11"
> white paper. Margins must be at least one (1) inch at the top, bottom,
> left and right of the paper. Please left-align text.

[]{.mark}

d.  Numbering

> Please number the pages of the application sequentially from page 1
> (face page) to the end of the application, including charts, figures,
> tables, and appendices.

e.  Names

> Please include the name of the applicant on each page.

f.  Section Headings

> Please put all section headings flush left in bold type.

**Application Format**

Applications for funding must consist of the following documents in the
following order:

[]{#__RefHeading___Toc55379027 .anchor}**i. Application Face Page**

> Standard Form 424, Public Health Service (PHS) Application Form
> 5161-1, is provided with the application package. Prepare this page
> according to instructions provided in the form itself. For information
> pertaining to the Catalog of Federal Domestic Assistance, the Catalog
> of Federal Domestic Assistance Number is 93.110.

**DUNS Number**

> All applicant organizations are required to have a Data Universal
> Numbering System (DUNS) number in order to apply for a grant from the
> Federal Government. The DUNS number is a unique nine-character
> identification number provided by the commercial company, Dun and
> Bradstreet. There is no charge to obtain a DUNS number. Information
> about obtaining a DUNS can be found at
> <http://www.hrsa.gov/grants/preview/dunsccr.htm> or call
> 1-866-705-5711. Please include DUNS number next to OMB Approval Number
> on the application face page. Applications ***will not*** be reviewed
> without a DUNS number.
>
> Additionally, the applicant organization will be required to register
> with the Federal Government's Central Contractor Registry (CCR) in
> order to do *electronic* business with the Federal Government.
> Information about registering with the CCR can be found at
> <http://www.hrsa.gov/grants/preview/dunsccr.htm>.

**ii. Table of Contents**

> Provide a Table of Contents for the remainder of the application
> (including appendices), with page numbers.

[]{#__RefHeading___Toc55379030 .anchor}**iii. Application Checklist**

Application Form 5161-1 can be downloaded from
[www.hrsa.gov/grants/forms/htm](http://www.hrsa.gov/grants/forms/htm).

[]{#__RefHeading___Toc55379031 .anchor}**iv. Budget**

> Please complete Sections A, B, E, and F, and then provide a line item
> budget for each grant year using the budget categories in the SF 424A.

[]{#__RefHeading___Toc55379032 .anchor}**v. Budget Justification**

> Provide a narrative that explains the amounts requested for each line
> in the budget. The budget justification should specifically describe
> how each item will support the achievement of proposed objectives. The
> budget period is for ONE year. However, the applicant must submit
> one-year budgets for each of the subsequent project period years
> (usually one to three years or more) at the time of application. The
> total in the line item budget must match totals entered on Standard
> Form 424A. Line item information must be provided to explain the costs
> entered in Standard Form 424A, Section B. The budget justification
> must clearly describe each cost element and explain how each cost
> contributes to meeting the project's objectives/goals. Be very careful
> about showing how each item in the "other" category is justified. The
> budget justification MUST be concise. Do NOT use the justification to
> expand the project narrative.
>
> This announcement is inviting applications for project periods up to
> three (3) years. Awards, on a competitive basis, will be for a
> one‑year budget period, although project periods may be for three (3)
> years. Applications for continuation grants funded under these three
> awards beyond the one-year budget period but within the three (3) year
> project period will be entertained in subsequent years on a
> noncompetitive basis, subject to availability of funds, satisfactory
> progress of the grantee and a determination that continued funding
> would be in the best interest of the Government.

[Include the following in the Budget Justification
narrative]{.underline}:

> *Personnel Costs*: Personnel costs should be explained by listing each
> staff member who will be supported from funds, name (if possible),
> position title, percent full time equivalency, annual salary, and the
> exact amount requested for each project year which mainly covers
> indirect cost.
>
> *Indirect Costs*: Indirect costs are those costs incurred for common
> or joint objectives which cannot be readily identified but are
> necessary to the operations of the organization, e.g., the cost of
> operating and maintaining facilities, depreciation, and administrative
> salaries. For institutions subject to OMB Circular A-21, the term
> "facilities and administration" is used to denote indirect costs. If
> the applicant does not have an indirect cost rate, you may obtain one
> by visiting the Division of Cost Allocation website:
> http://rates.psc.gov/.
>
> *Fringe Benefits*: List the components that comprise the fringe
> benefit rate, for example health insurance, taxes, unemployment
> insurance, life insurance, retirement plan, tuition reimbursement. The
> fringe benefits should be directly proportional to that portion of
> personnel costs that are allocated for the project.
>
> *Travel*: List travel costs according to local and long distance
> travel. For local travel, the mileage rate, number of miles, reason
> for travel and staff member/consumers completing the travel should be
> outlined. The budget should also reflect the travel expenses
> associated with participating in meetings and other proposed trainings
> or workshops.
>
> *Equipment*: List equipment costs and provide justification for the
> need of the equipment to carry out the program's goals. Extensive
> justification and a detailed status of current equipment must be
> provided when requesting funds for the purchase of computers and
> furniture items.
>
> *Supplies*: List the items that the project will use. In this
> category, separate office supplies from medical and educational
> purchases. Office supplies could include paper, pencils, and the like;
> medical supplies are syringes, blood tubes, plastic gloves, etc., and
> educational supplies may be pamphlets and educational videotapes.
> Remember, they must be listed separately.
>
> *Subcontracts*: To the extent possible, all subcontract budgets and
> justifications should be standardized, and contract budgets should be
> presented by using the same object class categories contained in the
> Standard Form 424A. Provide a clear explanation as to the purpose of
> each contract, how the costs were estimated, and the specific contract
> deliverables.
>
> *Other*: Put all costs that do not fit into any other category into
> this category and provide an explanation of each cost in this
> category. In some cases, grantee rent, utilities and insurance fall
> under this category if they are not included in an approved indirect
> cost rate.)

[]{#__RefHeading___Toc55379033 .anchor}**vi. Staffing Plan and Personnel
Requirements**

Applicants must present a staffing plan and provide a justification for
the plan that includes education and experience qualifications and
rationale for the amount of time being requested for each staff
position. Position descriptions that include the roles,
responsibilities, and qualifications of proposed project staff must be
included in the Appendix. Copies of biographical sketches for any key
employed personnel that will be assigned to work on the proposed project
must be included in the Appendix.

[]{#__RefHeading___Toc55379034 .anchor}**vii. Assurances**

Standard Form 424A, Form PHS 5161-1, downloadable from
[www.hrsa.gov/grants/forms/htm](http://www.hrsa.gov/grants/forms/htm).

[]{#__RefHeading___Toc55379035 .anchor}

**viii. Certifications**

Pages 17-19, Form PHS 5161-1 downloadable from
[www.hrsa.gov/grants/forms/htm](http://www.hrsa.gov/grants/forms/htm).

[]{#__RefHeading___Toc55379036 .anchor}**ix. Project Abstract**

> Provide a summary of the application. Because the abstract is often
> distributed to provide information to the public and Congress, please
> prepare this so that it is clear, accurate, concise, and without
> reference to other parts of the application. It must include a brief
> description of the proposed grant project including the needs to be
> addressed, the proposed services, and the population group(s) to be
> served.

*Please place the following at the top of the abstract:*

-   *Project Title*

-   *Applicant Name*

-   *Address*

-   *Contact Phone Numbers (Voice, Fax)*

-   *E-Mail Address*

-   *Web Site Address, if applicable*

> The project abstract must be single-spaced and limited to one page in
> length
>
> The project abstracts of all approved and funded applications will be
> widely distributed to MCHB grantees, Title V programs, academic
> institutions, and government agencies. A database of the abstracts is
> available at:

<http://www.ncemch.org/MCHPROJECTSsearch/mchbproj.html>

[]{#__RefHeading___Toc55379037 .anchor}**x. Program Narrative**

> This section provides a comprehensive framework and description of all
> aspects of the proposed program. It should be succinct,
> self-explanatory and well organized so that reviewers can understand
> the proposed project. Instructions for preparing each major section of
> the program narrative are followed by corresponding specific program
> criteria, which the Objective Review Panel will be instructed to use
> for their evaluation and rating of applications submitted.
>
> Your project narrative must include:

-   ***Introduction***

This section should briefly describe the purpose of the proposed
project.

-   ***Needs Assessment***

> This section outlines the needs of your community and/or organization.
> The target population and its unmet health needs must be described and
> documented in this section. Demographic data should be used and cited
> whenever possible to support the information provided. Please discuss
> any relevant barriers in the service area that the project hopes to
> overcome. If applicable, this section should help reviewers understand
> the community and/or organization that will be served by the proposed
> project.

-   ***Methodology***

> Propose methods that will be used to meet each of the
> previously-described program requirements and expectations in this
> grant announcement.

-   ***Work Plan***

> Describe the activities or steps that will be used to achieve each of
> the activities proposed in the methodology section. Use a time line
> that includes each activity and identifies responsible staff. The
> applicant is to include in this section activities necessary to carry
> out each approach.

-   ***Resolution Of Challenges***

> Discuss challenges that are likely to be encountered in designing and
> implementing the activities described in the Work Plan, and approaches
> that will be used to resolve such challenges.

-   ***Evaluation And Technical Support Capacity***

> Describe current experience, skills, and knowledge, including
> individuals on staff, materials published, and previous work of a
> similar nature.

-   ***Organizational Information***

> Provide information on the applicant agency's current mission and
> structure, scope of current activities, and an organizational chart,
> and describe how these all contribute to the ability of the
> organization to conduct the program requirements and meet program
> expectations.

[]{#__RefHeading___Toc55379038 .anchor}**xi. Program Specific Forms**

-   ***MCHB Discretionary Grant Performance Measures Data Forms***

> All data forms should be completed according to instructions on form.

[]{#__RefHeading___Toc55379039 .anchor}**xii. Appendices**

> Please provide the following items to complete the content of the
> application. Please note that these are supplementary in nature, and
> are not intended to be a continuation of the project narrative. Be
> sure each appendix is clearly labeled.

1.  ***Appendix A***: Tables, Charts, etc., to expound on the
    proposal**.**

2.  ***Appendix B***: Job Descriptions for Key Personnel

> Keep each to one page in length as much as possible. Item 6 the
> Program Narrative section of the PHS 5161-1 Form provides some
> guidance on items to include in a job description.
>
> **3) *Appendix C***: Biographical Sketches of Key Personnel
>
> Include biographical sketches for persons occupying the key positions
> described in Appendix B, not to exceed two pages in length. In the
> event that a biographical sketch is included for an identified
> individual who is not yet hired, please include a letter of commitment
> from that person with the biographical sketch.
>
> **4) *Appendix D***: Letters of Agreement and/or Description(s) of
> Proposed/Existing Contracts (project specific)
>
> Provide any documents that describe working relationships between the
> applicant agency and other agencies and programs cited in the
> proposal. Documents that confirm actual or pending contractual
> agreements should clearly describe the roles of the subcontractors and
> any deliverables.
>
> **5) *Appendix E***: Project Organizational Chart
>
> Provide a one-page figure that depicts the organizational structure of
> the project, including subcontractors and other significant
> collaborators.
>
> **6) *Appendix F***: Other Relevant Documents (e.g., Protocols,
> Letters of support, etc.) Include only letters of support which
> specifically indicate a commitment to the project/program (dollars,
> staff, space, equipment, etc.) Letters of agreement and support must
> be dated. List all other support letters on one page.

## 3. Submission Dates And Times {#submission-dates-and-times .unnumbered}

### Application Due Date {#application-due-date .unnumbered}

> The due date for applications under the *Innovative Approaches to
> Promoting a Healthy Weight in Women (H59)* grant announcement is
> *December 2, 2005 at 5:00 P.M. ET*.
>
> Applications will be considered as meeting the deadline if they are
> either:

(1) Received on or before the due date; or

(2) Postmarked or E-marked on or before the due date, and received in
    time for the Independent Review Committee review.

> The Chief Grants Management Officer (CGMO) or a higher level designee
> may authorize an extension of published deadlines when justified by
> circumstances such as acts of God (e.g. floods or hurricanes),
> widespread disruptions of mail service, or other disruptions of
> services, such as a prolonged blackout. The authorizing official will
> determine the affected geographical area(s).
>
> **Electronic Submission:**
>
> [Applications must be submitted by 5:00 P.M. ET on December 2,
> 2005]{.underline}. **To ensure that you have adequate time to follow
> procedures and successfully submit the application, we recommend you
> start submission no later than noon on the due date.** Applications
> submitted electronically will be time/date stamped electronically,
> which will serve as receipt of submission.
>
> **Paper Submission:**
>
> Upon receipt of a paper application, the Grants Application Center
> will mail an acknowledgement of receipt to the applicant
> organization's Program Director.
>
> In the event that questions arise about meeting the application due
> date, applicants must have a legibly dated receipt from a commercial
> carrier or the U.S. Postal Service. Private metered postmarks will not
> be accepted as proof of timely mailing.
>
> **Late Applications:**
>
> Applications which do not meet the criteria above are considered late
> applications. Health Resources and Services Administration (HRSA)
> shall notify each late applicant that its application will not be
> considered in the current competition.

**4. Intergovernmental Review**

> The *Innovative Approaches to Promoting a Healthy Weight in Women
> (H59* grant is subject to the provisions of Executive Order (EO)12372,
> as implemented by 45 CFR 100. Executive Order 12372, allows States
> *the option* of setting up a system for reviewing applications from
> within their States for assistance under certain Federal programs.
> Information on states affected by this program and State Points of
> Contact may also be obtained from the Grants Management Officer listed
> in the AGENCY Contact(s) section, as well as from the following Web
> site: <http://www.whitehouse.gov/omb/grants/spoc.html>.
>
> All applicants other than federally recognized Native American Tribal
> Groups should contact their SPOC as early as possible to alert them to
> the prospective applications and receive any necessary instructions on
> the State process used under this Executive Order.
>
> Letters from the State Single Point of Contact (SPOC) in response to
> Executive Order 12372 are due sixty days after the application due
> date.

**5. Funding Restrictions**

> Applicants responding to this announcement for the *Innovative
> Approaches to Promoting a Healthy Weight in Women (H59)* grant program
> may request funding for a project period of up to three (3) years, at
> no more than \$150,000 per year. **Applicants that submit budgets that
> exceed the \$150,000 per year maximum will be deemed *ineligible* and
> not be considered for funding.**
>
> Awards to support projects beyond the first budget year will be
> contingent upon Congressional appropriation, satisfactory progress in
> meeting the project's objectives, and a determination that continued
> funding would be in the best interest of the government.
>
> [Under current OMB regulations, funds under this announcement may not
> be used for the following purposes]{.underline}:
>
> **No Supplantation:** Funds may only be used to supplement and
> supplant other Federal or non-Federal funds that would otherwise be
> made available to the project.
>
> **Shared Staffing:** Applicants proposing to utilize the same director
> or contractual staff across multiple grant/programs (e.g., Title X
> Family Planning, Title V MCH) should assure that the combined funding
> for each position does not exceed 100% FTE. If such an irregularity is
> found, funding will be reduced accordingly.
>
> **Shared Equipment:** Applicants proposing to purchase equipment which
> will be used across multiple grants/programs (Title X Family Planning,
> Title V MCH) should pro-rate the costs of the equipment across
> programs and show the calculation of this pro-ration in their
> justification. If an irregularity is found where program equipment is
> being used by other programs without reimbursement, funding will be
> reduced accordingly.
>
> **Cash Stipends/Incentives:** Funds cannot be utilized for cash
> stipends/monetary incentives given to clients to enroll in project
> services. However, funds can be used to facilitate participation in
> project activities (e.g., transportation costs/tokens), as well as for
> services rendered to the project.
>
> **Purchase of Vehicles:** Projects should not allocate funds to buy
> vehicles for the transportation of clients, but rather lease vehicles
> or contract for these services.
>
> **No Lobbying:** Funds cannot be used to lobby the Executive or
> Legislative branches of the Federal government in connection with this
> initiative. All applicants should review and sign page 18 of PHS
> 5161-1 (Rev. 7/00) certifying that project funds are not being used
> for lobbying activities. Pursuant to Section 1352 of Title 31, United
> States Code, all grantees must now disclose any lobbying undertaken
> with non-Federal (non-appropriated funds). If non-Federal funds are
> being used for lobbying activities, grantees must disclose this
> information this information by completing Standard Form LLL
> "Disclosure of Lobbying Activities," page 27 of PHS 5161-1 (Rev.
> 7/00).

**6. Other Submission Requirements**

### Electronic Submission {#electronic-submission .unnumbered}

> You may submit your application to us either in electronic or paper
> format. To submit an application electronically, please use the
> [http://www.Grants.gov](http://www.Grants.gov/) apply site. If you use
> Grants.Gov you will be able to download a copy of the application
> package, complete it off-line, and then upload and submit the
> application via the Grants.gov site. You may not e-mail an electronic
> copy of a grant application to us.
>
> Please note the following if you plan to submit your application
> electronically via Grants.Gov:
>
> • Electronic submission is voluntary
>
> • When you enter the Grants.Gov site, you will find information about
> submitting an application electronically through the site, as well as
> the hours of operation. We strongly recommend that you do not wait
> until the application deadline date to begin the application process
> through Grants.Gov. The registration process is a separate process
> from submitting an application. **Applicants are, therefore,
> encouraged to register early**. The registration process can take
> approximately two weeks to be completed. Therefore, registration
> should be done in sufficient time to ensure it does not impact your
> ability to meet required submission deadlines. You will be able to
> submit your application online anytime after you receive your
> e-authentication credentials.
>
> • To use Grants.gov, you, as the applicant, must have a DUNS Number
> and register in the Central Contractor Registry (CCR). You should
> allow a minimum of five days to complete the CCR registration.
>
> • You will not receive additional point value because you submit a
> grant application in paper format.
>
> • You may submit all documents electronically, including all
> information typically included on the SF424 and all necessary
> assurances and certifications.
>
> • Your application must comply with any page limitation requirements
> described in this program announcement.
>
> • After you electronically submit your application, you will receive
> an automatic acknowledgement from Grants.Gov that contains a
> Grants.Gov tracking number. The Health Resources and Services
> Administration will retrieve your application from Grants. Gov.
>
> • You may access the electronic application for this program on
> [http://www.Grants.gov](http://www.Grants.gov/).
>
> • You must search for the downloadable application package by the CFDA
> number.
>
> • The grants.gov website provides customer support via (800)
> 518-GRANTS (this is a toll-free number) or through e-mail at
> [**support@grants.gov**](mailto:support@grants.gov). The customer
> support center is open from 7:00 a.m. to 9:00 p.m. Eastern time,
> Monday through Friday, except federal holidays, to address grants.gov
> technology issues. For technical assistance to program related
> questions, contact the number listed in the Program Section of the
> program you are applying for.
>
> Online applications are required to submit ONLY one form in signed
> hard copy: the SF-424/5161 Face Sheet, since all other elements of the
> application have been captured and transmitted electronically. 
>
> **Formal submission of the electronic application:** Applications
> completed online are considered formally submitted when the
> Authorizing Official electronically submits the application to HRSA.
> However, to complete the submission requirements, a hard-copy of the
> SF-424/5161 Face Sheet must be printed, signed, and submitted to the
> HRSA Grants Application Center. The SF-424/5161 can be printed from
> the online application.
>
>  
>
> For an online application, the signed SF-424/5161 must be sent to the
> HRSA GRANTS APPLICATION CENTER at the address below, and received by
> HRSA by no later than five days after the December 5, 2005 due date.
>
> Applications will be considered as having met the deadline if: (1) the
> application has been successfully transmitted electronically by your
> organization's Authorizing Official through Grants.Gov on or before
> the deadline date and time, and (2) the signed SF-424/5161 Face Sheet
> is postmarked on or before the deadline date and received in time for
> orderly processing and review.
>
>  
>
> REMINDER: Only applicants who apply online are permitted to forego
> hard-copy submission of all application forms EXCEPT the signed
> SF-424/5161.
>
>  
>
> If the application is submitted as a hard-copy, the rules of
> submission as described earlier in this guidance must be followed.

### Paper Submission  {#paper-submission .unnumbered}

> Paper applications, if you choose to submit a paper copy, please send
> the original and two (2) copies of the completed application to:
>
> The HRSA Grants Application Center
>
> The Legin Group, Inc.
>
> Attn: *Innovative Approaches to Promoting a Healthy Weight in Women
> (H59)*
>
> Program Announcement No. HRSA-06-063
>
> CFDA No. 93.110
>
> 901 Russell Avenue, Suite 450
>
> Gaithersburg, MD 20879
>
> Telephone: 877-477-2123
>
> In the event that questions arise about meeting the application due
> date, applicants must have a legibly dated receipt from a commercial
> carrier or the U.S. Postal Service. Private metered postmarks will not
> be accepted as proof of timely mailing.
>
> Whether you submit electronically or via paper, please understand that
> we will not consider additional information and/or materials submitted
> after your initial application,. You must therefore ensure that all
> materials are submitted together, whether electronically or on paper.

**V. APPLICATION REVIEW INFORMATION**

***Innovative Approaches to Promoting a Healthy Weight in Women***

[]{#__RefHeading___Toc55379053 .anchor} **Background**

> In 2002 President Bush launched HealthierUS - an initiative based on
> the premise that increasing personal fitness and becoming healthier is
> critical to achieving a better and longer life. The four pillars of
> HealthierUS encourage the expansion of opportunities for self
> empowerment by individuals: be physically active; eat a nutritious
> diet, get preventive screenings; make healthy choices. Overweight and
> obesity have been grouped as one of the Leading Health Indicators in
> *Healthy People 2010*. According to the 2001 *Surgeon General's Call
> to Action to Prevent and Decrease Overweight and Obesity* report, more
> than half of all Americans are either overweight or obese. If not
> addressed, overweight and obesity may soon cause as much preventable
> disease and death as cigarette smoking. A recent study (Finkelstein,
> Fiebelkorn, and Wang, 2003) found that American's extra weight costs
> the nation as much as \$93 billion in annual medical bills and the
> government pays about half that amount. This cost is comparable to the
> annual medical bill for smoking, which was estimated at about \$76
> billion a few years ago. Overall, the annual medical costs for an
> obese person are about 37.7 percent more or \$732 higher, than costs
> for someone of normal weight.
>
> How is overweight and obesity measured? Currently, Body Mass Index or
> BMI is the commonly used measure of overweight and obesity. BMI is a
> measure of weight in relation to height and is calculated in pounds
> divided by the square of the height in inches, multiplied by 703. NIH
> *Clinical Guidelines*, support the use of a BMI of 30 kg/m^2^ or
> greater to identify obesity in adults and a BMI between 25 kg/m^2^ and
> 29.9 kg/m^2^ to identify overweight in adults. BMI has some
> limitations in that it can overestimate body fat in persons who are
> very muscular, and it can underestimate body fat in persons who have
> lost muscle mass, such as many elderly. However, these definitions are
> based upon evidence that suggests health risks are greater at or above
> a BMI of 25 kg/m^2^ compared to those at a BMI below that level.
>
> Overweight women are at increased risk for hypertension, heart
> disease, diabetes and some types of cancer. Calle, et al, (2003)
> looked at the influence of excess body weight on the risk of death
> from cancer. Based upon the associations observed in the study, it was
> estimated that current patterns of overweight and obesity in the
> United States could account for 14 percent of all deaths from cancer
> in men and 20 percent of those in women.
>
> The concurrent rise in diabetes, including Type 2 and gestational
> diabetes, can also be linked to the rising rates of obesity. Diabetes
> is also more prevalent when coupled with pregnancy and obesity. Up to
> 19 percent of obese pregnant women have pre-gestational diabetes, and
> another 8 percent develop gestational onset diabetes (National
> Institutes of Health, 1998). Obese women are at high risk for
> childbearing complications and require more extensive nursing
> assessment and care throughout pregnancy and birth (Cesario, 2003).
> For the woman, being both pregnant and obese increases cardiac
> workload in addition to placing excessive strain on the
> musculoskeletal system. According to Watkins, et al, obese and
> overweight women face significantly increased risks of having babies
> with heart abnormalities and other birth defects (2003). These
> findings indicate that obesity prevention efforts must also emphasize
> the need to be a healthy weight before getting pregnant, or
> preconceptionally.
>
> The 1999-2000 National Health and Nutrition Examination Survey
> (NHANES) data shows that 62 percent of women ages 20-74 are
> overweight. In general the prevalence of overweight and obesity is
> higher in women who are members of racial and ethnic minority
> populations than in non-Hispanic white women. Disparities in
> prevalence also exist based on socioeconomic status. The NHANES data
> shows that among White, non-Hispanic women, 57.5 percent are
> overweight and 30.6 percent are obese; among Mexican-American women
> 71.8 percent are overweight and 40.1 percent are obese; and among
> Black women, 78 percent are overweight and 50.8 percent are obese. For
> all racial and ethnic groups combined, women of lower socioeconomic
> status are approximately 50 percent more likely to be obese than those
> with higher socioeconomic status. Developing interventions that are
> effective in reducing the prevalence of overweight/obesity is critical
> to improving the health of all women. The goal of this demonstration
> program is to develop and demonstrate creative, innovative approaches
> that are effective in reducing the incidence and prevalence of
> overweight/obesity in women by increasing the number of women who
> adopt positive, healthy lifestyles. The applicant must describe how
> they will identify women in need of services aimed at reducing the
> risks related to overweight/obesity, link them with programs such as
> Title V, Title X and other relevant health services and resources for
> appropriate follow-up and, include a means to evaluate success. *The
> interventions implemented must include nutrition counseling and
> education, physical activity, and a health and wellness component
> (e.g., health and wellness interventions could range from counseling*
> *about stress reduction/management to yoga).* The interventions
> implemented must be: 1) substantive in nature, i.e., go beyond
> screening, to positively impact the woman=s knowledge, attitudes and
> health behavior practices, 2) have documented efficacy as evidenced by
> cited literature and any other documentation, and 3) occur at regular
> intervals over a defined period of time, e.g, weekly classes for x
> number of weeks. These approaches should: a) target women in a variety
> of settings, e.g., churches, hair salons, etc.; b) create partnerships
> and/or strengthen existing linkages with other organizations from a
> variety of community settings; and c) be culturally appropriate. Other
> health promotion topics may be selected and addressed, as appropriate,
> through the applicant=s intervention program. *Proposals must include
> a focus on women who are disproportionately affected by
> overweight/obesity in the targeted geographic area, particularly
> racial and ethnic minority populations.*

##  1. Review Criteria {#review-criteria .unnumbered}

[]{.mark}

> Review Criteria are used to review and rank applications. The review
> process for applications submitted under *Innovative Approaches to
> Promoting a Healthy Weight in Women* will involve review by an
> Objective Review Committee (ORC) composed of multidisciplinary
> experts. The ORC will evaluate all eligible applications using the
> following weighted review criteria. Applicants should pay strict
> attention to addressing these criteria, as they are the basis upon
> which the reviewers will judge their applications.
>
> **[*Need*]{.underline} -- (20%):** The extent to which the application
> describes the problem and associated contributing factors to the
> problem.
>
> **Background** - Provide background information that adequately
> supports the need to promote a healthy weight in women for the
> geographical area described. Describe the current availability of
> preventive health services for women, including any that address
> overweight/obesity and associated risk factors among women. Applicants
> must justify any additional associated risk factors that will be
> included in the intervention. Applicants must provide demonstrated
> evidence of expertise in the development and implementation of similar
> risk reduction initiatives.
>
> **Need** -- Thoroughly describe the need for the project in the
> proposed locale including baseline data on the number and demographic
> characteristics of women in the targeted population including
> racial/ethnic data. Provide a description of the prevalence of
> overweight and obesity in the proposed geographic area. Provide
> current data on access to preventive health services and data on
> health behaviors in the targeted population should also be included in
> the description.
>
> ***[Response]{.underline}* -- (30%):** *The extent to which the
> proposed project responds to the "Purpose" included in the program
> description. The clarity of the proposed goals and objectives and
> their relationship to the identified project. The extent to which the
> activities (scientific or other) described in the application is
> capable of addressing the problem and attaining the project
> objectives.*
>
> **Proposed Plan** -- Describe how the proposed health promotion
> recruitment and intervention activities, referral linkages,
> partnerships, and venues reflect the needs of the women in the
> community and those at risk for overweight/obesity with demonstrated
> evidence of community input and involvement. The plan must develop and
> utilize methods that are effective in stimulating positive health
> behavior practices related to attaining and maintaining a healthy
> weight with the appropriate community health programs and services for
> follow-up to address overweight and obesity issues. The plan should
> consider the context of the women=s lives and include ways in which
> the women can be active participants in the maintenance of their own
> personal health.
>
> *The interventions implemented must include nutrition counseling and
> education, physical activity, and a health and wellness component;
> health and wellness interventions could range from counseling about
> stress reduction/management to yoga*. Additionally, the proposed
> interventions must be: 1) substantive in nature, i.e., go beyond
> screening, e.g., weekly classes for x number of weeks, to positively
> impact the women's knowledge, attitudes and health behavior practices;
> 2) have documented efficacy as evidenced by cited literature and any
> other documentation; and 3) occur at regular intervals over a defined
> period of time. Approaches should target women, in a variety of
> community settings, e.g., churches, beauty salons, etc.; and create
> partnerships and/or strengthen existing linkages with other
> organizations from a variety of settings. **A proposal must include a
> focus on women who are disproportionately affected by
> overweight/obesity, particularly racial and ethnic minority
> populations.**
>
> **Project Goals and Objectives** -- Present appropriate goals and
> objectives in relation to the specific nature of State and local
> needs, the specified program requirements. Objectives should be
> time-framed and measurable, consistent with the overall goal of the
> program as stated, and reflect the unique needs of the women targeted.
>
> **Methodology** -- In addition to the goals, objectives and activities
> listed above, describe the project plan, e.g., methodology, and its
> relation to the projects goals and objectives, and each program
> requirement. This includes detailed descriptions of:

-   proposed sample size, including a description of strategies that
    will be used to identify and enroll sufficient numbers of women in
    need of overweight/obesity risk reduction services to demonstrate an
    effect;

-   detailed description of proposed intervention program including
    recruitment plan, location and frequency of interventions such as
    nutrition and exercise classes, support groups,
    counseling/education, and justification as to adequacy,
    innovativeness and cultural appropriateness;

-   evidence of efficacy of the proposed approaches such as cited
    literature, references to use and effectiveness of intervention in
    other programs;

-   methods for tracking the types of interventions applied, including
    referrals, contacts made for additional services, and documentation
    of the provision of such services;

-   methods to include representatives of the targeted population in the
    decision-making process, with specific strategies to develop and/or
    strengthen and maintain community partnerships; and,

-   the specific plans for dissemination of best practices and lessons
    learned.

> **[*Evaluative Measures*]{.underline} -- (15%):** *The effectiveness
> of the method proposed to monitor and evaluate the project results.
> Evaluative measures must be able to assess (1) to what extent the
> program objectives have been met and (2) to what extent these can be
> attributed to the project.*
>
> **Evaluation Plan** -- Present an evaluation plan that describes how
> improvements in addressing targeted areas will be measured over time
> for the population of program participants (eg. pretest, post-test).
> Applicants will be assessed on the quality and feasibility of the plan
> as to how well it evaluates the degree of adoption of positive health
> behaviors by the women into their everyday lives. The level of impact
> on the knowledge, skills, attitudes, and behaviors of the women to
> routinely make healthy choices. For the purposes of this project, the
> focus is on demonstrated improvements in knowledge and behavior.
>
> **Monitoring and Measurement** -- Describe the process to identify,
> measure, and track key activities related to the achievement of
> project goals and objectives and their compliance with MCHB=s
> evaluation protocol for discretionary grants and cooperative
> agreements. The methods for tracking the types of interventions
> applied, e.g., smoking cessation or cooking classes, including
> referrals, contacts made for additional services, and documentation of
> the provision of such services.
>
> ***[Impact]{.underline}* -- (10%):** *The extent and effectiveness of
> plans for dissemination of project results, and/or the extent to which
> project results may be national in scope and/or the degree to which a
> community is impacted by delivery of health services, and/or the
> degree to which the project activities are replicable, and/or the
> sustainability of the program beyond Federal funding. Impact will be
> measured by the extent to which:*

-   the proposed plan positively impacts and strengthens linkages with
    other women's health care services/systems, in a variety of
    community settings;

-   the project will contribute to the improvement of the health status
    of women of reproductive age; and,

-   the proposed interventions are routinely integrated into other
    women's health services/systems.

> ***[Resources/Capabilities]{.underline}* - (15%):** *The extent to
> which project personnel are qualified by training and/or experience to
> implement and carry out the project. The capabilities of the applicant
> organization, and quality and availability of facilities and personnel
> to fulfill the needs and requirements of the proposed project. For
> competing continuations, past performance will also be considered.*
>
> **Experience and Capability** -- Describe the extent to which the
> applicant has demonstrated expertise and capability to successfully
> carry out the project. Describe the applicant's expertise in providing
> health promotion services to women.
>
> **Capacity Building** -- Present evidence reflecting the strategies to
> be used and the extent to which the applicant plans to sustain
> community partnerships developed in the targeted community beyond the
> life of the project. Also, describe the extent to which linkages with
> other women's health programs, e.g., Community Centers of Excellence
> in Women's Health and Centers of Excellence in Women's Health in other
> community settings will increase accessibility to services and
> resources, as well as support and facilitate positive health behavior
> practices.
>
> **Staff Capability** -- Provide evidence that a sufficient number of
> project personnel and resources are proposed, with appropriate
> qualifications, to carry out the project effectively within proposed
> timeframe. The applicant must include curricula vitas of the proposed
> project personnel which documents relevant education, skills, and
> experience that are necessary for the proposed project.
>
> ***[Support Requested]{.underline}* -- (10%):** *The reasonableness of
> the proposed budget in relation to the objectives, the complexity of
> the activities, and the anticipated results.*
>
> **Budget Summary** -- Present a budget that is consistent with the
> proposed activities for **each of the budget years** requested for the
> three-year project period.
>
> **Itemized Justification** -- Present a line item budget (SF 424A
> form) and the coinciding justification to support **each of the three
> budget years.** A justification for each of the requested items
> relative to the project plan including person hours for staff, travel
> items, equipment, contractual services, supplies, and other categories
> must be provided. Travel cost justification must include who, where,
> length of time, purpose and associated costs for each trip. Applicants
> must budget one trip a year for up to two persons for three days to
> Washington, D.C. **Applications submitted without a budget and
> justification for each budget year requested may not be favorably
> considered for funding. Additionally, applicants that submit budgets
> that exceed the \$150,000 per year maximum will be deemed *ineligible*
> and not be considered for funding.**
>
> **Contractual Services** -- Provide an adequate justification and
> description for all necessary contractual services including the scope
> and costs.

**2. Review and Selection Process**

> The Division of Independent Review is responsible for managing
> objective reviews within HRSA. Applications competing for federal
> funds receive an objective and independent review performed by a
> committee of experts qualified by training and experience in
> particular fields or disciplines related to the program being
> reviewed. In selecting review committee members, other factors in
> addition to training and experience may be considered to improve the
> balance of the committee, e.g. geographic distribution,
> race/ethnicity, and gender. Each reviewer is screened to avoid
> conflicts of interest and is responsible for providing an objective,
> unbiased, evaluation based on the review criteria noted above. The
> committee provides expert advice on the merits of each application to
> program officials responsible for final selections for award.

3.  **Anticipated Award Date**

> May 1, 2006[]{#__RefHeading___Toc55379061 .anchor} is the anticipated
> date of award.

**VI. AWARD ADMINISTRATION INFORMATION**

## 1. Award Notices  {#award-notices .unnumbered}

> Each applicant will receive written notification of the outcome of the
> objective review process, including a summary of the expert
> committee's assessment of the application's merits and weaknesses, and
> whether the application was selected for funding. Applicants who are
> selected for funding may be required to respond in a satisfactory
> manner to Conditions placed on their application before funding can
> proceed. Letters of notification do not provide authorization to begin
> performance. The Notice of Grant Award, which is signed by the Grants
> Management Officer and is sent to the applicant agency's Authorized
> Representative, is the authorizing document. It will be sent prior to
> the start date of May 1, 2006.

##  2. Administrative and National Policy Requirements {#administrative-and-national-policy-requirements .unnumbered}

> Successful applicants must comply with the administrative requirements
> outlined in 45 CFR Part 74 or 45 CFR Part 92, as appropriate.

###   {#section .unnumbered}

###  {#section-1 .unnumbered}

### Healthy People 2010  {#healthy-people-2010 .unnumbered}

> Healthy People 2010 is a national initiative led by HHS that sets
> priorities for all HRSA programs. The initiative has two major goals:
> (1) to increase the quality and years of a healthy life; and (2)
> eliminate our country's health disparities. The program consists of 28
> focus areas and 467 objectives. HRSA has actively participated in the
> work groups of all the focus areas, and is committed to the
> achievement o the Healthy People 2010 goals.
>
> Applicants must summarize the relationship of their projects and
> identify which of their programs objectives and/or sub-objectives
> related to the goals of the Healthy People 2010 initiative.
>
> Copies of the Healthy People 2010 may be obtained from the
> Superintendent of Documents or downloaded at the Healthy People 2010
> website:
> [www.health.gov/healthypeople/document/](http://www.health.gov/healthypeople/document/),
>
> or call 1-800-367-4725.
>
> Successful applicants must comply with the administrative requirements
> outlined in 45 CFR Part 74 (non-governmental entities) or 45 CFR Part
> 92 (non-Federal governmental entities).

###  Smoke-Free Workplace  {#smoke-free-workplace .unnumbered}

> The Public Health Service strongly encourages all award recipients to
> provide a smoke-free workplace and to promote the non-use of all
> tobacco products. Further, Public Law 103-227, the Pro-Children Act of
> 1994, prohibits smoking in certain facilities (or in some cases, any
> portion of a facility) in which regular or routine education, library,
> day care, health care or early childhood development services are
> provided to children.

###  Special Concerns {#special-concerns .unnumbered}

> HRSA's Maternal and Child Health Bureau places special emphasis on
> improving service delivery to women, children, and youth from
> communities with limited access to comprehensive care. This same
> special emphasis applies to improving service delivery to children
> with special health care needs. In order to assure access and cultural
> competence, it is expected that projects will involve individuals from
> the populations to be served in the planning and implementation of the
> project. The Bureau's intent is to ensure that project interventions
> are responsive to the cultural and linguistic need of special
> populations, that services are accessible to consumers, and that the
> broadest possible representation of culturally distinct and
> historically under-represented groups is supported through programs
> and projects sponsored by the MCHB.

###  Cultural Competence {#cultural-competence .unnumbered}

> In order to assure access and cultural competence, it is expected that
> projects will involve individuals from the populations to be served in
> the planning and implementation of the project. The Bureau\'s intent
> is to ensure that project interventions are responsive to the cultural
> and linguistic needs of special populations, that services are
> accessible to consumers, and that the broadest possible representation
> of culturally distinct and historically under represented groups is
> supported through programs and projects sponsored by the MCHB.

###  {#section-2 .unnumbered}

###  Family Participation {#family-participation .unnumbered}

> It is also expected that projects will retain the family centered
> approach to which the Bureau is committed. This approach recognizes
> that the family is the constant in a child's life, while service
> systems and their attendant personnel fluctuate. It facilitates
> family/professional collaboration at all levels of care, including
> program development, implementation, policy formation and evaluation.
> Family-centered care ensures that services and support systems are
> flexible, accessible, and comprehensive in responding these
> family-identified needs.

[]{.mark}

###  Program Monitoring  {#program-monitoring .unnumbered}

> MCHB views program accountability, including monitoring, assessment,
> and evaluation, as an important tool for ongoing program improvement.
> All Maternal and Child Health Bureau supported programs must, at
> minimum monitor program activities and report annually, utilizing the
> performance measures below.

The Government Performance and Results Act (GPRA), Public Law 103-62,
requires that the Federal agency establish performance measures that can
be reported as part of the budgetary process, thus linking funding
decisions with performance and reviewing related outcome measures to see
if there were improved outcomes for the target population.

> In fiscal year 2003, MCHB's performance measures for discretionary
> grants were approved by the Office of Management and Budget (OMB).
>
> MCHB must include these measures in its annual reports to Congress on
> the actual performance achieved by its programs compared to that
> proposed in the performance plan.
>
> Performance measures specific to these three (3) grant programs are
> included in this guidance (see Appendices). Program activities, as
> measured by these performance measures, should have a collective
> contributory effect to positively impact the outcome measures for the
> target population.

Program accountability is determined by: a) providing budget and
expenditure amounts by the four levels of service represented in the MCH
pyramid; b) measuring progress toward achieving performance measures;
and, c) having a positive impact on the outcome measures if the program
activities are effective and successful. While improvement in outcome
measures is the long-term goal, more immediate success may be realized
by positive impact on the capacity, process, and risk factor performance
measures, which are shorter term, intermediate, and precursors for the
outcome measures. This is particularly important since there may be
other significant factors outside of the program's control affecting
outcomes.

> Applications are required to describe the capacity of the applicant to
> collect and report the data required in the performance measures on an
> on-going basis.

###   {#section-3 .unnumbered}

###  Federal Responsibilities  {#federal-responsibilities .unnumbered}

> Once the grant is awarded, MCHB will monitor and evaluate the project
> activities funded under this competition. Program monitoring may
> include guidance, consultation, technical assistance, facilitation of
> conferences, and/or communications with the award recipients which are
> conducted to review mutually agreed upon goals and objectives, to
> assess progress, and to provide technical assistance. The outcome of
> monitoring activities could lead to adjustments in funding and
> priority tasks for a project.
>
> *Performance Review*
>
> HRSA's Office of Performance Review (OPR) serves as the agency's focal
> point for reviewing and enhancing the performance of HRSA funded
> programs within communities and States. As part of this agency-wide
> effort, HRSA grantees will be required, where appropriate, during
> their project period to participate in an on-site performance review
> of their HRSA funded program(s) by an OPR review team. When a grantee
> receives more than one HRSA grant, each of the grantee's HRSA funded
> programs will be reviewed during the same performance review. For
> additional information on performance reviews, please visit:
> <http://www.hrsa.gov/performancereview>.
>
> Upon completion of the performance review, grantees will be required
> to prepare an Action Plan to address any identified program
> requirement issues as well as identify key actions to improve program
> performance. In addition, performance reviews also provide an
> opportunity for grantees to offer direct feedback to the agency about
> the impact of HRSA policies on program implementation and performance
> within communities and States.

[]{#__RefHeading___Toc55379071 .anchor} **3. Reporting**

[The successful applicant under this guidance must]{.underline}:

a\. Comply with audit requirements of Office of Management and Budget
(OMB) Circular A-133. Information on the scope, frequency, and other
aspects of the audits can be found on the Internet at
[www.whitehouse.gov/omb/circulars](http://www.whitehouse.gov/omb/circulars);

b\. Submit a Payment Management System Quarterly Report. The reports
identify cash expenditures against the authorized funds for the grant.
Failure to submit the report may result in the inability to access grant
funds. [Submit report to the]{.underline}:

> Division of Payment Management
>
> DPM/FMS/PSC/ASAM/HHS
>
> PO Box 6021
>
> Rockville, MD 20852
>
> Telephone: (301) 443-1660;

c\. Submit a Financial Status Report. A financial status report is
required within 90 days of the end of each grant year. The report is an
accounting of expenditures under the project that year;

> d\. Submit a Progress Report(s). A successful applicant under this
> notice will submit reports in accordance with the provisions of the
> general regulations that apply ("Monitoring and Reporting Program
> Performance" 45 CFR Part 74.51 and Part 92.40). Successful applicants
> will be required to provide an annual progress report. The progress
> report will be included in the continuation application each year. The
> progress report should include: (1) a brief summary of overall project
> accomplishments during the reporting period, including any barriers to
> progress that have been encountered and strategies/steps taken to
> overcome them; (2) progress on specific goals and objectives as
> outlined in this application and revised in consultation with the
> Federal project officer; (3) current staffing, including the roles and
> responsibilities of each staff and a discussion of any difficulties in
> hiring or retaining staff; (4) technical assistance needs; and (5) a
> description of linkages that have been established with other
> programs.

e.  Final Report. The project's final report and any products developed
    through the grant are to be provided to the Division of Grants
    Management within 90 days of the end of the project period, which
    will forward these materials to the Project Officer. The Project
    Officer will provide these final reports and products to the MCH
    Library for public access.

> f\. Post-Award Reporting. **Successful applicants receiving grant
> funds will be required, within 120 days of the Notice of Grant Award
> (NGA), to register in HRSA's Electronic Handbooks (EHBs) and
> electronically complete the program specific data forms that appear in
> Appendices A and B of this guidance.** This requires the provision of
> budget breakdowns in the financial forms based on the grant award
> amount, the project abstract and other grant summary data, and
> objectives for the performance measures.

[]{#__RefHeading___Toc55379072 .anchor}**VII. Agency Contacts**

Applicants are encouraged to request assistance in the development of
the application.

> For additional information regarding business, administrative, or
> fiscal issues related to these grant announcements, applicants may
> contact:
>
> Ms. Valerie A. Barton
>
> Division of Grants Management Operations
>
> Health Resources and Services Administration
>
> Parklawn Building, Room 11A-16
>
> 5600 Fishers Lane
>
> Rockville, Maryland 20857
>
> Telephone: (301) 443-4580
>
> Fax: (301) 443-6096
>
> Email: <vbarton@hrsa.gov>
>
> To obtain additional information relating to technical and program
> issues under the *Innovative Approaches to Promoting a Healthy Weight
> in Women (H59)* grant program, applicants may contact:
>
> Lisa R. King, MA
>
> Program Director, Women's Health
>
> Maternal and Child Health Bureau, HRSA
>
> Parklawn Building, Room 18-12
>
> 5600 Fishers Lane
>
> Rockville, MD 20857
>
> Telephone: (301)443-5720
>
> Fax: (301)594-0186
>
> E-Mail: <LKing@hrsa.gov>

**VIII.** []{#__RefHeading___Toc55379073 .anchor}**Tips for Writing a
Strong Application**

> **Include DUNS Number.** You must include DUNS Number to have your
> application reviewed. Application ***will not*** be reviewed without a
> DUNS number. If applicants are submitting an application on or after
> October 1, 2003 a DUNS number is required. To obtain a DUNS number,
> access [www.dunandbradstreet.com](http://www.dunandbradstreet.com/) or
> call 1-866-705-5711. Please include DUNS number next to OMB Approval
> Number on the application face page.
>
> **Keep your audience in mind.** Reviewers will use only the
> information contained in the application to assess the application.
> Therefore, be sure the application and responses to the program
> requirements and expectations are complete and clearly written. Do not
> assume that reviewers are familiar with the applicant organization.
> Keep the review criteria in mind when writing the application.
>
> **Start preparing the application early.** Allow plenty of time to
> gather required information from various sources.
>
> **Follow the instructions in this guidance carefully.** Place all
> information in the order requested in the guidance. If the information
> is not placed in the requested order, you may receive a lower score.
>
> **Be brief, concise, and clear.** Make your points understandable.
> Provide accurate and honest information, including candid accounts of
> problems and realistic plans to address them. If any required
> information or data is omitted, explain why. Make sure the information
> provided in each table, chart, attachment, etc., is consistent with
> the proposal narrative and information in other tables.
>
> **Be organized and logical.** Many applications fail to receive a high
> score because the reviewers cannot follow the thought processes of the
> applicant or because parts of the application do not fit together.
>
> **Be careful in the use of appendices.** Do not use the appendices for
> information that is required in the body of the application. Be sure
> to cross-reference all tables and attachments located in the
> appendices to the appropriate text in the application.
>
> **Carefully proofread the application.** Misspellings and grammatical
> errors will impede reviewers in understanding the application. Be sure
> pages are numbered (including appendices) and that page limits are
> followed. Limit the use of abbreviations and acronyms, and define each
> one at its first use and periodically throughout application.
>
> **Print out and carefully review an electronic application**. If
> submitting electronically, print out the application before submitting
> it to ensure appropriate formatting and adherence to page limit
> requirements.
>
> ***This page intentionally left blank***

**APPENDIX A \-\-\-- REPORTING FORMS**

**FORM 1**

**MCHB PROJECT BUDGET DETAILS FOR FY \_\_\_\_\_\_\_**

**1. MCHB GRANT AWARD AMOUNT** \$\_\_\_\_\_\_\_\_\_**\_**

**2. UNOBLIGATED BALANCE** \$\_\_\_\_\_\_\_\_\_**\_**

**3. MATCHING FUNDS** (Required: Yes \[ \] No \[ \] If yes, amount)
\$\_\_\_\_\_\_\_\_\_\_

> A. Local funds \$\_\_\_\_\_\_\_

B.  State funds \$\_\_\_\_\_\_\_

C.  Program Income \$\_\_\_\_\_\_\_

D.  Applicant/Grantee Funds \$\_\_\_\_\_\_\_

E.  E. Other funds \$\_\_\_\_\_\_\_

**4. OTHER PROJECT FUNDS** (Not included in 3 above)
\$\_\_\_\_\_\_\_\_\_\_

> A. Local funds \$\_\_\_\_\_\_\_

B.  State funds \$\_\_\_\_\_\_\_

C.  Program Income (Clinical or Other) \$\_\_\_\_\_\_\_

D.  Applicant/Grantee Funds (includes in-kind) \$\_\_\_\_\_\_\_

> E. Other funds (including private sector, e.g., \$\_\_\_\_\_\_\_
>
> Foundations)

**5**. **TOTAL PROJECT FUNDS** (Total lines 1 through 4)
\$\_\_\_\_\_\_\_\_\_\_

**6. FEDERAL COLLABORATIVE FUNDS**

(Source(s) of additional Federal funds contributing to the project)

> Other MCHB Funds (Do not repeat grant funds from Line 1)
>
> 1\) SPRANS \$\_\_\_\_\_\_\_\_
>
> 2\) CISS \$\_\_\_\_\_\_\_\_
>
> 3\) SSDI \$\_\_\_\_\_\_\_\_
>
> 4\) Abstinence Education \$\_\_\_\_\_\_\_\_
>
> 5\) Healthy Start \$\_\_\_\_\_\_\_\_

6)  EMSC \$\_\_\_\_\_\_\_\_

7)  Bioterrorism \$\_\_\_\_\_\_\_\_

8)  Traumatic Brain Injury \$\_\_\_\_\_\_\_\_

9)  State Title V Block Grant \$\_\_\_\_\_\_\_\_

10) Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \$\_\_\_\_\_\_\_\_

> Other HRSA Funds
>
> 1\) HIV/AIDS \$\_\_\_\_\_\_\_\_

2\) Primary Care \$\_\_\_\_\_\_\_\_

3\) Health Professions \$\_\_\_\_\_\_\_\_

4\) Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \$\_\_\_\_\_\_\_\_

Other Federal Funds

1\) CMS \$\_\_\_\_\_\_\_\_

2\) SSI \$\_\_\_\_\_\_\_\_

3\) Agriculture (WIC/other) \$\_\_\_\_\_\_\_\_

4\) ACF \$\_\_\_\_\_\_\_\_

5\) CDC \$\_\_\_\_\_\_\_\_

6\) SAMHSA \$\_\_\_\_\_\_\_\_

7\) NIH \$\_\_\_\_\_\_\_\_

8\) Education \$\_\_\_\_\_\_\_\_

9\) Other: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \$\_\_\_\_\_\_\_\_

> \$\_\_\_\_\_\_\_\_
>
> \$\_\_\_\_\_\_\_\_

**7. TOTAL COLLABORATIVE FEDERAL FUNDS**
\$[\_\_\_\_\_\_\_\_]{.underline}

**OMB \# 0915-0272**

**Expiration date:  January 31, 2006**

**INSTRUCTIONS FOR COMPLETION OF FORM 1**

**MCH BUDGET DETAILS FOR FY 2005**

Line 1. Enter the amount of the Federal MCHB grant award for this
project.

Line 2. Enter the amount of carryover from the previous year's award, if
any (the unobligated balance).

Line 3. Indicate if matching funds are required by checking the
appropriate choice. If matching funds are required, enter the total
amount of the matching funds received or committed to the project. List
the amounts by source on lines 3A through 3D as appropriate. Do not
include "overmatch" funds. Any additional funds over and above the
amount required for matching purposes should be reported in Line 4.
Where appropriate, include the dollar value of in-kind contributions.

Line 4. Enter the amount of other funds received for the project, by
source on Lines 4A through 4E, specifying amounts from each source. Do
not include those amounts included in Line 3 above. Also include the
dollar value of in-kind contributions.

Line 5. Enter the sum of lines 1 through 4

Line 6. Line 6. Enter the amount of other Federal funds received on the
appropriate lines (A.1 through C.9) **other** than the MCHB grant award
for the project. Such funds would include those from other Departments,
other components of the Department of Health and Human Services, or
other MCHB grants or contracts.

Line 6C.1. Enter only project funds from the Center for Medicare and
Medicaid Services. Exclude Medicaid reimbursement, which is considered
Program Income and should be included on Line 3C or 4C.

If lines 6A.10, 6B.4, or 6C.9 are utilized, specify the source(s) of the
funds in the order of the amount provided, starting with the source of
the most funds. If more space is required, add a footnote at the bottom
of the page showing additional sources and amounts.

Line 7. Enter the sum of Lines 6A.1 through 6C.9.

NOTE: MCHB Training Grants must fill out Section "V. Detailed Budget" of
the currently approved HRSA-6025 in addition to this form.

**OMB \# 0915-0272**

**Expiration date:  January 31, 2006**

**FORM 2**

**PROJECT FUNDING PROFILE**

> [FY]{.underline} [FY]{.underline} [FY]{.underline} [FY]{.underline}
> [FY]{.underline}\_\_\_\_\_
>
> [Budgeted Expended]{.underline} [Budgeted Expended]{.underline}
> [Budgeted Expended]{.underline} [Budgeted Expended]{.underline}
> [Budgeted Expended]{.underline}

1.  [MCHB Grant]{.underline}

[Award]{.underline} [Amount]{.underline} \$ \$ \$ \$ \$ \$ \$ \$
\$\_\_\_\_\_\_\_ \$ \_\_\_\_\_\_\_\_

(*Line 1, Form 2)*

2\. [Unobligated]{.underline}

[Balance]{.underline} \$ \$ \$ \$ \$ \$ \$ \$ \$\_\_\_\_\_\_\_ \$
\_\_\_\_\_\_\_\_ *(Line 2, Form 2)*

3\. [Matching]{.underline}

[Funds]{.underline}

[(If required)]{.underline} \$ \$ \$ \$ \$ \$ \$ \$ \$\_\_\_\_\_\_\_ \$
\_\_\_\_\_\_\_\_

(*Line 3, Form 2)*

4*.* [Other Project]{.underline}

[Funds]{.underline} \$ \$ \$ \$ \$ \$ \$ \$ \$\_\_\_\_\_\_\_ \$
\_\_\_\_\_\_\_\_

(*Line 4, Form 2)*

5\. [Total Project]{.underline}

[Funds]{.underline} \$ \$ \$ \$ \$ \$ \$ \$ \$\_\_\_\_\_\_\_ \$
\_\_\_\_\_\_\_\_

(*Line 5, Form 2)*

6\. [Total Federal]{.underline}

[Collaborative]{.underline}

[Funds]{.underline} \$ \$ \$ \$ \$ \$ \$ \$ \$\_\_\_\_\_\_\_ \$
\_\_\_\_\_\_\_\_

*(Line 7, Form 2)*

**OMB \# 0915-0272**

**Expiration date:  January 31, 2006**

**INSTRUCTIONS FOR THE COMPLETION OF FORM 2**

**PROJECT FUNDING PROFILE**

**Instructions:**

Complete all required data cells. If an actual number is not available,
use an estimate. Explain all estimates in a footnote.

The form is intended to provide at a glance funding data on the
estimated budgeted amounts and actual expended amounts of an MCH
project.

> For each fiscal year, the data in the columns labeled Budgeted on this
> form are to contain the same figures that appear on the Application
> Face Sheet and Lines 1 through 7 of Form 1. The lines under the
> columns labeled Expended are to contain the actual amounts expended
> for each grant year that has been completed.

**OMB \# 0915-0272**

**Expiration date:  January 31, 2006**

**FORM 4**

**PROJECT BUDGET AND EXPENDITURES**

**By Types Of Services**

**FY \_\_\_\_\_ FY \_\_\_\_\_**

> **[TYPES OF SERVICES]{.underline} [Budgeted]{.underline}
> [Expended]{.underline} [Budgeted]{.underline} [Expended]{.underline}**

**I. [Direct Health Care Services]{.underline}** \$ \$ \$ \$
[\_\_\_\_\_\_\_\_\_]{.underline}

> (Basic Health Services and Health
>
> Services for CSHCN.)

**II. [Enabling Services]{.underline}** \$ \$ \$ \$
[\_\_\_\_\_\_\_\_\_\_]{.underline}

> (Transportation, Translation,
>
> Outreach, Respite Care, Health
>
> Education, Family Support Services,
>
> Purchase of Health Insurance,
>
> Case Management, and Coordination
>
> with Medicaid, WIC, and Education.)

**III.** **[Population-Based Services]{.underline}** \$ \$ \$
\$\_\_\_\_\_\_\_\_\_\_\_

> (Newborn Screening, Lead Screening,
>
> Immunization, Sudden Infant Death
>
> Syndrome Counseling, Oral Health,
>
> Injury Prevention, Nutrition, and
>
> Outreach/Public Education.)

**IV.** **[Infrastructure Building Services]{.underline}** \$ \$ \$ \$
[\_\_\_\_\_\_\_\_\_\_\_]{.underline}

> (Needs Assessment, Evaluation, Planning,
>
> Policy Development, Coordination,
>
> Quality Assurance, Standards Development,
>
> Monitoring, Training, Applied Research,
>
> Systems of Care, and Information Systems.)

**V. TOTAL** \$ \$ \$ \$ [\_\_\_\_\_\_\_\_\_\_]{.underline}

**OMB \# 0915-0272**

**Expiration date:  January 31, 2006**

**INSTRUCTIONS FOR THE COMPLETION OF FORM 4**

**PROJECT BUDGET AND EXPENDITURES BY TYPES OF SERVICE**S

Complete all required data cells. If an actual number is not available,
make an estimate. Please explain all estimates in a footnote.
Administrative dollars should be allocated to the appropriate level(s)
of the pyramid on lines I, II, II or IV. If an estimate of
administrative funds use is necessary, one method would be to allocate
those dollars to Lines I, II, III and IV at the same percentage as
program dollars are allocated to Lines I through IV.

Note: Lines I, II and II are for projects providing services. If grant
funds are used to build the infrastructure for direct care delivery,
enabling or population-based services, these amounts should be reported
in Line IV (i.e., building data collection capacity for newborn hearing
screening).

Line I [Direct Health Care Services]{.underline} - enter the budgeted
and expended amounts for the appropriate fiscal year completed and
budget estimates only for all other years.

> **Direct Health Care Services** are those services generally delivered
> one-on-one between a health professional and a patient in an office,
> clinic or emergency room which may include primary care physicians,
> registered dietitians, public health or visiting nurses, nurses
> certified for obstetric and pediatric primary care, medical social
> workers, nutritionists, dentists, sub-specialty physicians who serve
> children with special health care needs, audiologists, occupational
> therapists, physical therapists, speech and language therapists,
> specialty registered dietitians. Basic services include what most
> consider ordinary medical care, inpatient and outpatient medical
> services, allied health services, drugs, laboratory testing, x-ray
> services, dental care, and pharmaceutical products and services. State
> Title V programs support - by directly operating programs or by
> funding local providers - services such as prenatal care, child health
> including immunizations and treatment or referrals, school health and
> family planning. For CSHCN, these services include specialty and
> sub-specialty care for those with HIV/AIDS, hemophilia, birth defects,
> chronic illness, and other conditions requiring sophisticated
> technology, access to highly trained specialists, or an array of
> services not generally available in most communities.

Line II [Enabling Services]{.underline} - enter the budgeted and
expended amounts for the appropriate fiscal year completed and budget
estimates only for all other years.

> **Enabling Services** allow or provide for access to and the
> derivation of benefits from, the array of basic health care services
> and include such things as transportation, translation services,
> outreach, respite care, health education, family support services,
> purchase of health insurance, case management, coordination of with
> Medicaid, WIC and educations. These services are especially required
> for the low income, disadvantaged, geographically or culturally
> isolated, and those with special and complicated health needs. For
> many of these individuals, the enabling services are essential - for
> without them access is not possible. Enabling services most commonly
> provided by agencies for CSHCN include transportation, care
> coordination, translation services, home visiting, and family
> outreach. Family support activities include parent support groups,
> family training workshops, advocacy, nutrition and social work.

Line III [Population-Based Services]{.underline} - enter the budgeted
and expended amounts for the appropriate fiscal year completed and
budget estimates only for all other years.

> **Population Based Services** are preventive interventions and
> personal health services, developed and available for the entire MCH
> population of the State rather than for individuals in a one-on-one
> situation. Disease prevention, health promotion, and statewide
> outreach are major components. Common among these services are newborn
> screening, lead screening, immunization, Sudden Infant Death Syndrome
> counseling, oral health, injury prevention, nutrition and
> outreach/public education. These services are generally available
> whether the mother or child receives care in the private or public
> system, in a rural clinic or an HMO, and whether insured or not.

Line IV [Infrastructure Building Services]{.underline} - enter the
budgeted and expended amounts for the appropriate fiscal year completed
and budget estimates only for all other years.

> **Infrastructure Building Services** are the base of the MCH pyramid
> of health services and form its foundation. They are activities
> directed at improving and maintaining the health status of all women
> and children by providing support for development and maintenance of
> comprehensive health services systems and resources including
> development and maintenance of health services standards/guidelines,
> training, data and planning systems. Examples include needs
> assessment, evaluation, planning, policy development, coordination,
> quality assurance, standards development, monitoring, training,
> applied research, information systems and systems of care. In the
> development of systems of care it should be assured that the systems
> are family centered, community based and culturally competent.

Line V [Total]{.underline} -- enter the total amounts for each column,
budgeted for each year and expended for each year completed.

**OMB \# 0915-0272**

**Expiration date:  January 31, 2006**

**FORM 5**

**NUMBER OF INDIVIDUALS SERVED (UNDUPLICATED)**

**By Type of Individual and Source of Primary Insurance Coverage**

**[For Projects Providing Direct Health Care, Enabling or
Population-based Services]{.underline}**

**Reporting Year**\_\_\_\_\_\_\_\_\_\_

######### **Table 1** (a) (b) (c) (d) (e) (f) {#table-1-a-b-c-d-e-f .unnumbered}

+-----------+--------+--------+---------+---------+---------+-------+
| *         | **     | **T    | **Title | **Title | **Pri   | **N   |
| *Pregnant | Number | otal** | XIX %** | XXI %** | vate/** | one** |
| Women     | Se     |        |         |         |         |       |
| Served**  | rved** | **Se   |         |         | **Other | **%** |
|           |        | rved** |         |         | %**     |       |
+-----------+--------+--------+---------+---------+---------+-------+
| Pregnant  |        |        |         |         |         |       |
| Women     |        |        |         |         |         |       |
|           |        |        |         |         |         |       |
| (All      |        |        |         |         |         |       |
| Ages)     |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 10-14     |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 15-19     |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 20-24     |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 25-34     |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 35-44     |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 45 +      |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+

> **Table 2** (a) (b) (c) (d) (e) (f)

+-----------+--------+--------+---------+---------+---------+-------+
| **C       | **     | *      | **Title | **Title | **Pri   | **N   |
| hildren** | Number | *Total | XIX %** | XXI %** | vate/** | one** |
|           | Se     | Se     |         |         |         |       |
| *         | rved** | rved** |         |         | **Other | **%** |
| *Served** |        |        |         |         | %**     |       |
+-----------+--------+--------+---------+---------+---------+-------+
| Infants   |        |        |         |         |         |       |
| \<1       |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| Children  |        |        |         |         |         |       |
|           |        |        |         |         |         |       |
| 1 to 22   |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 1-4       |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 5-9       |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 10-14     |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 15-19     |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 20-24     |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+

######### **Table 3 (a) (b) (c) (d) (e) (f)** {#table-3-a-b-c-d-e-f .unnumbered}

+-----------+--------+--------+---------+---------+---------+-------+
| **CSHCN** | **     | **T    | **Title | **Title | **Pri   | **N   |
|           | Number | otal** | XIX %** | XXI %** | vate/** | one** |
| *         | Se     |        |         |         |         |       |
| *Served** | rved** | **Se   |         |         | **Other | **%** |
|           |        | rved** |         |         | %**     |       |
+-----------+--------+--------+---------+---------+---------+-------+
| Infants   |        |        |         |         |         |       |
| \<1       |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| Children  |        |        |         |         |         |       |
|           |        |        |         |         |         |       |
| 1 to 22   |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 1-4       |        | []{    | []      | []      | []      | []{.  |
|           |        | .mark} | {.mark} | {.mark} | {.mark} | mark} |
+-----------+--------+--------+---------+---------+---------+-------+
| 5-9       |        | []{    | []      | []      | []      | []{.  |
|           |        | .mark} | {.mark} | {.mark} | {.mark} | mark} |
+-----------+--------+--------+---------+---------+---------+-------+
| 10-14     |        | []{    | []      | []      | []      | []{.  |
|           |        | .mark} | {.mark} | {.mark} | {.mark} | mark} |
+-----------+--------+--------+---------+---------+---------+-------+
| 15-21     |        | []{    | []      | []      | []      | []{.  |
|           |        | .mark} | {.mark} | {.mark} | {.mark} | mark} |
+-----------+--------+--------+---------+---------+---------+-------+

**OMB \# 0915-0272**

**Expiration date:  January 31, 2006**

######## **[FORM 5 Continued]{.underline}**

**NUMBER OF INDIVIDUALS SERVED (UNDUPLICATED)**

**By Type of Individual and Source of Primary Insurance Coverage**

**[For Projects Providing Direct Health Care, Enabling or
Population-based Services]{.underline}**

**Reporting Year**\_\_\_\_\_\_\_\_\_\_

> **Table 4** (a) (b) (c) (d) (e) (f)

+-----------+--------+--------+---------+---------+---------+-------+
| **Women** | **     | **T    | **Title | **Title | **Pri   | **N   |
|           | Number | otal** | XIX %** | XXI %** | vate/** | one** |
| *         | Se     |        |         |         |         |       |
| *Served** | rved** | **Se   |         |         | **Other | **%** |
|           |        | rved** |         |         | %**     |       |
+-----------+--------+--------+---------+---------+---------+-------+
| Women 22  |        |        |         |         |         |       |
| +         |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 22-24     |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 25-29     |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 30-34     |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 35-44     |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 45-54     |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 55-64     |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 65 +      |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+

> **Table 5** (a) (b) (c) (d) (e) (f)

+-----------+--------+--------+----------+---------+---------+-------+
| **Other** | **Nu   | **T    | **Title  | **Title | **Pri   | **N   |
|           | mber** | otal** | XIX**    | XXI**   | vate/** | one** |
|           |        |        |          |         |         |       |
|           | **Se   | **Se   | **%**    | **%**   | **Other | **%** |
|           | rved** | rved** |          |         | %**     |       |
+-----------+--------+--------+----------+---------+---------+-------+
|           |        |        |          |         |         |       |
+-----------+--------+--------+----------+---------+---------+-------+

###### Table 6 (a) (b) (c) (d) (e) (f) {#table-6-a-b-c-d-e-f .unnumbered}

+----------+--------+--------+----------+--------+---------+--------+
| #######  | **Nu   | **T    | **Title  | *      | **Pri   | **     |
|  TTOTALS | mber** | otal** | XIX**    | *Title | vate/** | None** |
|          |        |        |          | XXI**  |         |        |
|          | **Se   | **Se   | **%**    |        | **Other | **%**  |
|          | rved** | rved** |          | **%**  | %**     |        |
+----------+--------+--------+----------+--------+---------+--------+
|          |        |        |          |        |         |        |
+----------+--------+--------+----------+--------+---------+--------+

> **INSTRUCTIONS FOR THE COMPLETION OF FORM 5**

**NUMBER OF INDIVIDUALS SERVED (UNDUPLICATED)**

**By Type of Individual and Source of Primary Insurance Coverage**

**[For Projects Providing Direct Health Care, Enabling or
Population-based Services]{.underline}**

**Instructions:**

Enter data into all required (unshaded) data cells. If an actual number
is not available, make an estimate. Please explain all estimates in a
footnote. Do not enter data into shaded cells.

**[Note]{.underline}** that ages are expressed as either x to y,
[not]{.underline} through y (i.e., 1 to 22, meaning from age 1 [up
to]{.underline} age 22, but not including 22), or x -- y (i.e., 1- 4)
meaning age 1 [through]{.underline} age 4. Also, symbols are used to
indicate directions. For example \<1 means less than 1, or from birth up
to, but not including age 1. On the other hand, 45+ means age 45 and
over.

1\. At the top of the Form, on the Line Reporting Year, enter the year
for which the data applies.

2.  In Column (a) for all tables, enter the unduplicated count of
    individuals who received a direct service from the project
    regardless of the primary source of insurance coverage. These
    services would generally be included in the top three levels of the
    MCH pyramid (the fourth, or base level, would generally not contain
    direct services) and would include individuals served by total
    dollars reported on Line 5 of Form 3.

3\. In Column (b), enter the total number of the individuals summed from
Column (a).

4.  In the remaining columns report, for all tables, the percentage of
    those individuals receiving direct health care, enabling or
    population-based services, the percentage who have as their primary
    source of coverage:

> Column (c): Title XIX (includes Medicaid expansion under Title XXI)

Column (d): Title XXI

Column (e): Private or other coverage

Column (f) None

> These may be estimates. If individuals are covered by more than one
> source of insurance, they should be listed under the column of their
> [primary]{.underline} source.

**INSTRUCTIONS FOR THE COMPLETION OF FORM 6**

**PROJECT ABSTRACT**

**NOTE:** All information provided should fit into the space provided in
the form. The completed form should be no more than 3 pages in length.

**Section I - Project Identifier Information**

Project Title: List the appropriate shortened title for the project.

Project Number: This is the number assigned to the project when funded,
and will, for new projects, be filled in later.

E-mail address: Include electronic mail addresses

#### Section II - Budget - These figures will be transferred from Form 2, Lines 1 through 5.  {#section-ii---budget---these-figures-will-be-transferred-from-form-2-lines-1-through-5. .unnumbered}

####  {#section-4 .unnumbered}

#### Section III - Types of Services - Indicate which type(s) of services your project provides, checking all that apply (consistent with Form 5) {#section-iii---types-of-services---indicate-which-types-of-services-your-project-provides-checking-all-that-apply-consistent-with-form-5 .unnumbered}

#### Section IV - Program Description OR Current Status (DO NOT EXCEED THE SPACE PROVIDED) {#section-iv---program-description-or-current-status-do-not-exceed-the-space-provided .unnumbered}

A. New Projects only are to complete the following items:

1.  A brief description of the project and the problem it addresses such
    as preventive and primary care services for pregnant women, mothers,
    and infants; preventive and primary care services for children; and
    services for Children with Special Health Care Needs.

2.  Up to 5 goals of the project, in priority order. Examples are: ATo
    reduce the barriers to the delivery of care for pregnant women, @
    Ato reduce the infant mortality rate for minorities@ and "services
    or system development for children with special healthcare needs."
    MCHB will capture annually every project=s top goals in an
    information system for comparison, tracking, and reporting purposes;
    you must list at least 1 and no more than 5 goals. For each goal,
    list the two most important objectives. The objective must be
    specific (I.e., decrease incidence by 10%) and time limited (by
    2005).

3.  List the primary Healthy people 2010 goal(s) that the project
    addresses.

4.  Describe the programs and activities used to attain the goals and
    objectives, and comment on innovation, cost, and other
    characteristics of the methodology, proposed or are being
    implemented. Lists with numbered items can be used in this section.

5.  Describe the coordination planned and carried out, in the space
    provided, if applicable, with appropriate State and/or local health
    and other agencies in areas(s) served by the project.

6.  Briefly describe the evaluation methods that will be used to assess
    the success of the project in attaining its goals and objectives.

7.  Indicate the products of the project, if applicable.

8.  Briefly state how these products are/will be disseminated.

B. For continuing projects ONLY:

Provide a brief description of the major activities and accomplishments
over the past year (not to exceed 200 words). Also include website and
number of hit annually, if applicable.

**Section V -** **Key Words**

Key words describe the project, including populations served.

**Section VI -Annotation**

> Provide a three- to five-sentence description of your project that
> identifies the project's purpose, the needs and problems, which are
> addressed, the goals and objectives of the project, the activities,
> which will be used to attain the goals, and the materials, which will
> be developed.

**OMB \# 0915-0272**

**Expiration date:  January 31, 2006**

> **FORM 6**

**MATERNAL & CHILD HEALTH DISCRETIONARY GRANT**

**PROJECT ABSTRACT**

**FOR FY\_\_\_\_**

**PROJECT:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**I. PROJECT IDENTIFIER INFORMATION**

1\. Project Title:

2\. Project Number:

3\. E-mail address:

**II. BUDGET**

1\. MCHB Grant Award \$\_\_\_\_\_\_\_\_\_\_\_\_\_

(Line 1, Form 2)

2\. Unobligated Balance \$\_\_\_\_\_\_\_\_\_\_\_\_\_

(Line 2, Form 2)

3\. Matching Funds (if applicable) \$\_\_\_\_\_\_\_\_\_\_\_\_\_

> (Line 3, Form 2)

4\. Other Project Funds \$\_\_\_\_\_\_\_\_\_\_\_\_\_

> (Line 4, Form 2)

5\. Total Project Funds \$\_\_\_\_\_\_\_\_\_\_\_\_\_

> (Line 5, Form 2)

#### III. TYPE(S) OF SERVICE PROVIDED (Choose all that apply) {#iii.-types-of-service-provided-choose-all-that-apply .unnumbered}

\[ \] Direct Health Care Services

> \[ \] Enabling Services
>
> \[ \] Population-Based Services
>
> \[ \] Infrastructure Building Services

##### PROJECT DESCRIPTION OR EXPERIENCE TO DATE

> A. Project Description

1.  Problem (in 50 words, maximum):

2.  Goals and Objectives: (List up to 5 major goals and time-framed
    objectives per goal for the project)

> Goal 1:

Objective 1:

Objective 2:

Goal 2:

Objective 1:

Objective 2:

Goal 3:

Objective 1:

Objective 2:

Goal 4:

Objective 1:

Objective 2:

Goal 5:

Objective 1:

Objective 2:

3.  Activities undertaken to meet project goals:

4.  Specify the primary *Healthy People 2010* objectives(s) (up to
    three) which this project addresses:

> a\.
>
> b\.
>
> c\.

5\. Coordination (List the State, local health agencies or other
organizations involved in the project and their roles)

6\. Evaluation (briefly describe the methods which will be used to
determine whether process and outcome objectives are met)

#####  {#section-5 .unnumbered}

#####  {#section-6 .unnumbered}

##### Continuing Grants ONLY

##### Experience to Date (For continuing projects ONLY): 

> 2\. Website URL and annual number of hits

##### KEY WORDS

#### VI. ANNOTATION {#vi.-annotation .unnumbered}

[]{#__RefHeading___Toc55379074 .anchor}**OMB \# 0915-0272**

**Expiration date:  January 31, 2006**

**FORM 7**

**DISCRETIONARY GRANT PROJECT**

**SUMMARY DATA**

1.  **Project Service Focus**

> \[ \] Urban/Central City \[ \] Suburban \[ \] Metropolitan Area (city
> & suburbs)
>
> \[ \] Rural \[ \] Frontier \[ \] Border (US-Mexico)

2.  **Project Scope**

> \[ \] Local \[ \] Multi-county \[ \] State-wide
>
> \[ \] Regional \[ \] National

3.  **Grantee Organization Type**

> \[ \] State Program

\[ \] Community Government Program

\[ \] School District

\[ \] University/Institution Of Higher Learning (Non-Hospital Based)

\[ \] Academic Medical Center

\[ \] Community-Based Non-Governmental Organization (Health Care)

\[ \] Community-Based Non-Governmental Organization (Non-Health Care)

\[ \] Professional Membership Organization (Individuals Constitute Its
Membership)

\[ \] National Organization (Other Organizations Constitute Its
Membership)

\[ \] National Organization (Non-Membership Based)

\[ \] Independent Research/Planning/Policy Organization

\[ \] Other
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

4.  **Project Infrastructure Focus** (from MCH Pyramid) if applicable

\[ \] Guidelines/Standards Development And Maintenance

\[ \] Policies And Programs Study And Analysis

\[ \] Synthesis Of Data And Information

\[ \] Translation Of Data And Information For Different Audiences

\[ \] Dissemination Of Information And Resources

\[ \] Quality Assurance

\[ \] Technical Assistance

\[ \] Training

\[ \] Systems Development

\[ \] Other

**5. Products and Dissemination**

  -------------------------------------------------------- --------------
  **PRODUCTS**                                             **NUMBER**

  Peer reviewed Journal Article                            

  Book/Chapter                                             

  Report/Monograph                                         

  Presentation                                             

  Doctoral Dissertation                                    

  Other:                                                   
  -------------------------------------------------------- --------------

**6. Demographic Characteristics of Project Participants for Clinical
Services Projects**

+-----------+--------+------+--------+--------+-------+-------+-----+---+
|           | **RACE |      |        |        |       | **E   |     |   |
|           | (In    |      |        |        |       | THNIC |     |   |
|           | dicate |      |        |        |       | ITY** |     |   |
|           | all    |      |        |        |       |       |     |   |
|           | that   |      |        |        |       |       |     |   |
|           | ap     |      |        |        |       |       |     |   |
|           | ply)** |      |        |        |       |       |     |   |
+===========+========+======+========+========+=======+=======+=====+===+
|           | Am     | A    | Black  | Native | White | His   | Not |   |
|           | erican | sian | or     | Ha     |       | panic | Hi  |   |
|           | Indian |      | A      | waiian |       | or    | spa |   |
|           | or     |      | frican | or     |       | L     | nic |   |
|           | Alaska |      | Am     | Other  |       | atino |     |   |
|           | Native |      | erican | P      |       |       | or  |   |
|           |        |      |        | acific |       |       | Lat |   |
|           |        |      |        | Is     |       |       | ino |   |
|           |        |      |        | lander |       |       |     |   |
+-----------+--------+------+--------+--------+-------+-------+-----+---+
| Pregnant  |        |      |        |        |       |       |     |   |
| Women     |        |      |        |        |       |       |     |   |
+-----------+--------+------+--------+--------+-------+-------+-----+---+
| Children  |        |      |        |        |       |       |     |   |
+-----------+--------+------+--------+--------+-------+-------+-----+---+
| Children  |        |      |        |        |       |       |     |   |
| with      |        |      |        |        |       |       |     |   |
| Special   |        |      |        |        |       |       |     |   |
| Health    |        |      |        |        |       |       |     |   |
| Care      |        |      |        |        |       |       |     |   |
| Needs     |        |      |        |        |       |       |     |   |
+-----------+--------+------+--------+--------+-------+-------+-----+---+
| Women     |        |      |        |        |       |       |     |   |
|           |        |      |        |        |       |       |     |   |
| (Not      |        |      |        |        |       |       |     |   |
| Pregnant) |        |      |        |        |       |       |     |   |
+-----------+--------+------+--------+--------+-------+-------+-----+---+
| Other     |        |      |        |        |       |       |     |   |
+-----------+--------+------+--------+--------+-------+-------+-----+---+
| *         |        |      |        |        |       |       |     |   |
| *TOTALS** |        |      |        |        |       |       |     |   |
+-----------+--------+------+--------+--------+-------+-------+-----+---+

7.  Clients' Primary Language(s)

    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

8.  Resource/TA and Training Centers ONLY

    **Answer all that apply.**

    a.  Characteristics of Primary Intended Audience(s)

> \[ \] Policy Makers/Public Servants
>
> \[ \] Consumers

\[ \] Providers/Professionals

b\. Number of Requests Received/Answered: \_\_\_/\_\_\_\_

c.  Number of Continuing Education credits provided: \_\_\_\_\_\_\_

d.  Number of Individuals/Participants Reached: \_\_\_\_\_\_\_

e.  Number of Organizations Assisted: \_\_\_\_\_\_\_

f.  Major Type of TA or Training Provided:

> \[ \] continuing education courses,

\[ \] workshops,

\[ \] on-site assistance,

\[ \] distance learning classes

\[ \] other

**OMB \# 0915-0272**

**Expiration date:  January 31, 2006**

> **INSTRUCTIONS FOR THE COMPLETION OF FORM 7**

**PROJECT SUMMARY**

**NOTE:** All information provided should fit into the space provided in
the form. Where information has previously been entered in forms 2
through 9, the information will automatically be transferred
electronically to the appropriate place on this form.

**Section 1 -- Project Service Focus**

Select all that apply.

**Section 2 -- Project Scope**

Choose the one that best applies to your project.

**Section 3 -- Grantee Organization Type**

Choose the one that best applies to your organization.

**Section 4 -- Project Infrastructure Focus**

If applicable, choose all that apply.

**Section 5 -- Products and Dissemination**

Indicate the number of each type of product resulting from the project.

**Section 6 -- Demographic Characteristics of Project Participants (for
Clinical Services Projects)**

Please fill in each of the cells as appropriate.

**Section 7 -- Clients Primary Language(s) (for Clinical Services
Projects)**

Indicate which languages your clients speak as their primary language,
other than English. List up to three.

**Section 8 -- Resource/TA and Training Centers (Only)**

Answer all that apply.

# APPENDIX B - PERFORMANCE MEASURES {#appendix-b---performance-measures .unnumbered}

# PERFORMANCE MEASURE FOR:  {#performance-measure-for .unnumbered}

# INNOVATIVE APPROACHES TO PROMOTING A HEALTHY WEIGHT IN WOMEN (H59) {#innovative-approaches-to-promoting-a-healthy-weight-in-women-h59 .unnumbered}

+-----------------------------------+-----------------------------------+
| # 10 PERFORMANCE MEASURE {        | The degree to which MCHB          |
| #performance-measure .unnumbered} | supported programs have           |
|                                   | incorporated cultural competence  |
| **Goal 2: Eliminate Health        | elements into their policies,     |
| Barriers & Disparities**          | guidelines, contracts and         |
|                                   | training.                         |
| **(Develop and promote health     |                                   |
| services and systems of care      | **(NOTE: Also use Form 9 to       |
| designed to eliminate disparities | report this measure.)**           |
| and barriers across MCH           |                                   |
| populations)**                    |                                   |
|                                   |                                   |
| **Level: Grantee**                |                                   |
|                                   |                                   |
| **Category: Cultural Competence** |                                   |
+-----------------------------------+-----------------------------------+
| **GOAL**                          | To increase the number of MCHB    |
|                                   | supported programs that have      |
|                                   | integrated cultural competence    |
|                                   | into their policies, guidelines,  |
|                                   | contracts and training.           |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **MEASURE**                       | The degree to which MCHB          |
|                                   | supported programs have           |
|                                   | incorporated cultural competence  |
|                                   | elements into their policies,     |
|                                   | guidelines, contracts and         |
|                                   | training.                         |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **DEFINITION**                    | Attached is a checklist of 23     |
|                                   | elements that demonstrate         |
|                                   | cultural competency. Please check |
|                                   | the degree to which the elements  |
|                                   | have been implemented. The answer |
|                                   | scale is 0-69. Please keep the    |
|                                   | completed checklist attached.     |
+-----------------------------------+-----------------------------------+
| **HEALTHY PEOPLE 2010 OBJECTIVE** | Related to Objective 16.23:       |
|                                   | Increase the proportion of States |
|                                   | and jurisdictions that have       |
|                                   | service systems for children with |
|                                   | or at risk for chronic and        |
|                                   | disabling conditions as required  |
|                                   | by Public Law 101-239.            |
|                                   |                                   |
|                                   | Related to Objective 23.11        |
|                                   | (Developmental) Increase the      |
|                                   | proportion of State and local     |
|                                   | public health agencies that meet  |
|                                   | national performance standards    |
|                                   | for essential public health       |
|                                   | services.                         |
|                                   |                                   |
|                                   | Related to Objective 23.15        |
|                                   | (Developmental) Increase the      |
|                                   | proportion of Federal, Tribal,    |
|                                   | State, and local jurisdictions    |
|                                   | that review and evaluate the      |
|                                   |                                   |
|                                   | extent to which their statutes,   |
|                                   | ordinances, and bylaws assure the |
|                                   | delivery of essential public      |
|                                   | health services.                  |
+-----------------------------------+-----------------------------------+
| **DATA SOURCE(S) AND ISSUES**     | -   Attached data collection form |
|                                   |     to be completed by grantees.  |
|                                   |                                   |
|                                   | -   There is no existing national |
|                                   |     data source to measure the    |
|                                   |     extent to which MCHB          |
|                                   |     supported programs have       |
|                                   |     incorporated cultural         |
|                                   |     competence elements into      |
|                                   |     their policies, guidelines,   |
|                                   |     contracts and training.       |
+-----------------------------------+-----------------------------------+
| **SIGNIFICANCE**                  | Over the last decade, researchers |
|                                   | and policymakers have emphasized  |
|                                   | the central influence of cultural |
|                                   | values and cultural/linguistic    |
|                                   | barriers: health seeking          |
|                                   | behavior, access to care, and     |
|                                   | racial and ethnic disparities. In |
|                                   | accordance with these concerns,   |
|                                   | cultural competence objectives    |
|                                   | have been: (1) incorporated into  |
|                                   | the MCHB strategic plan; and (2)  |
|                                   | in guidance materials related to  |
|                                   | the Omnibus Budget Reconciliation |
|                                   | Act of 1989 (OBRA '89), which is  |
|                                   | the legislative mandate that      |
|                                   | health programs supported by MCHB |
|                                   | Children with Special Health Care |
|                                   | Needs (CSHCN) provide and promote |
|                                   | family centered, community‑based, |
|                                   | coordinated care.                 |
+-----------------------------------+-----------------------------------+

## DATA COLLECTION FORM FOR DETAIL SHEET #10

Using a scale of 0-3, please rate the degree to which your grant program
has incorporated the following cultural competence elements into your
policies, guidelines, contracts and training.

+------+------+------+------+------------------------------------------+
| *    | *    | *    | *    | **Element**                              |
| *0** | *1** | *2** | *3** |                                          |
+------+------+------+------+------------------------------------------+
|      |      |      |      | **CORE FUNCTIONS:** Our organization     |
|      |      |      |      | incorporates the following culturally    |
|      |      |      |      | competent core function elements:        |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 1.  Performs needs/assets assessments    |
|      |      |      |      |     with the culturally diverse groups   |
|      |      |      |      |     we serve.                            |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 2.  Collects and analyzes data according |
|      |      |      |      |     to different cultural groups (e.g.   |
|      |      |      |      |     race, ethnicity, language).          |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 3.  Designs services to meet the needs   |
|      |      |      |      |     of culturally diverse groups (e.g.   |
|      |      |      |      |     use of traditional healers, flexible |
|      |      |      |      |     times of services, language          |
|      |      |      |      |     services).                           |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 4.  Uses data on different groups for    |
|      |      |      |      |     program development.                 |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 5.  Considers barriers and the provision |
|      |      |      |      |     of appropriate strategies to address |
|      |      |      |      |     them.                                |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 6.  Evaluates and monitors quality       |
|      |      |      |      |     services (via customer satisfaction  |
|      |      |      |      |     surveys, focus groups, chart         |
|      |      |      |      |     reviews).                            |
+------+------+------+------+------------------------------------------+
|      |      |      |      | Is there a policy to incorporate         |
|      |      |      |      | cultural competence in the core          |
|      |      |      |      | functions? *None\_\_\_ Informal\_\_\_    |
|      |      |      |      | Formal\_\_\_ In process\_\_\_*           |
+------+------+------+------+------------------------------------------+
|      |      |      |      | **TRAINING/HUMAN RESOURCES**: Our        |
|      |      |      |      | organization incorporates the following  |
|      |      |      |      | culturally competent training/human      |
|      |      |      |      | resource elements:                       |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 1.  Employs a culturally diverse and     |
|      |      |      |      |     linguistically and culturally        |
|      |      |      |      |     competent staff.                     |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 2.  Ensures the provision of training,   |
|      |      |      |      |     both in orientation and ongoing      |
|      |      |      |      |     professional development, for staff, |
|      |      |      |      |     volunteers, contractors and          |
|      |      |      |      |     subcontractors in the area of        |
|      |      |      |      |     cultural and linguistic competence.  |
+------+------+------+------+------------------------------------------+
|      |      |      |      | Is there a policy to incorporate         |
|      |      |      |      | cultural competence in training and      |
|      |      |      |      | human resources?                         |
|      |      |      |      |                                          |
|      |      |      |      | *None\_\_\_ Informal\_\_\_ Formal\_\_\_  |
|      |      |      |      | In process\_\_\_*                        |
+------+------+------+------+------------------------------------------+
|      |      |      |      | **COLLABORATION:** Our organization      |
|      |      |      |      | collaborates with informal community     |
|      |      |      |      | leaders/groups (e.g. natural networks,   |
|      |      |      |      | informal leaders, spiritual leaders,     |
|      |      |      |      | ethnic media, family advocacy groups) in |
|      |      |      |      | various aspects of the following         |
|      |      |      |      | categories::                             |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 1.  Program planning                     |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 2.  Service delivery                     |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 3.  Evaluation/monitoring of services    |
+------+------+------+------+------------------------------------------+
|      |      |      |      | **COLLABORATION:** Our organization      |
|      |      |      |      | collaborates with families of culturally |
|      |      |      |      | diverse groups in various aspects of the |
|      |      |      |      | following categories:                    |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 4.  Program planning                     |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 5.  Service delivery                     |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 6.  Evaluation/monitoring of services    |
+------+------+------+------+------------------------------------------+
|      |      |      |      | Is there a policy to support the above   |
|      |      |      |      | mentioned collaborative activities?      |
|      |      |      |      | *None\_\_\_ Informal\_\_\_ Formal\_\_\_  |
|      |      |      |      | In process\_\_\_*                        |
+------+------+------+------+------------------------------------------+

+------+------+------+------+------------------------------------------+
|      |      |      |      | **RESOURCE ALLOCATION:** Our             |
|      |      |      |      | organization's allocation of resources   |
|      |      |      |      | adequately meets the unique access,      |
|      |      |      |      | information and service needs of         |
|      |      |      |      | culturally diverse groups in the         |
|      |      |      |      | following program areas:                 |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 1.  Planning                             |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 2.  Implementation                       |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 3.  Evaluation/Monitoring (e.g. customer |
|      |      |      |      |     satisfaction surveys, focus groups)  |
+------+------+------+------+------------------------------------------+
|      |      |      |      | Is there a policy to support the         |
|      |      |      |      | allocation of fiscal resources for the   |
|      |      |      |      | needs and services for culturally        |
|      |      |      |      | diverse groups?                          |
|      |      |      |      |                                          |
|      |      |      |      | *None\_\_\_ Informal\_\_\_ Formal\_\_\_  |
|      |      |      |      | In process\_\_\_*                        |
+------+------+------+------+------------------------------------------+
|      |      |      |      | **CONTRACTS:** Our agency puts language  |
|      |      |      |      | in contracts that addresses our goals to |
|      |      |      |      | incorporate cultural competence for      |
|      |      |      |      | culturally and linguistically diverse    |
|      |      |      |      | groups in the following areas**:**       |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 1.  Needs/assets assessments             |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 2.  Outreach                             |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 3.  Specialized services                 |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 4.  Training for                         |
|      |      |      |      |     contractors/subcontractors           |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 5.  Sufficient funds to support 1-e      |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 6.  Reporting requirements for a-e       |
+------+------+------+------+------------------------------------------+
|      |      |      |      | Is there a policy to support monitoring  |
|      |      |      |      | of contractors/ subcontractors?          |
|      |      |      |      |                                          |
|      |      |      |      | *None\_\_\_ Informal\_\_\_ Formal\_\_\_  |
|      |      |      |      | In process\_\_\_*                        |
+------+------+------+------+------------------------------------------+

0=Not Met

1=Partially Met

2=Mostly Met

3=Completely Met

Total the numbers in the boxes (possible 0‑69 score)
\_\_\_\_\_\_\_\_\_\_

**APPENDIX B -- PERFORMANCE MEASURES con't:**

+-----------------------------------+-----------------------------------+
| ####  21 PERFORMANCE MEASURE  {#p | The number of women participating |
| erformance-measure-1 .unnumbered} | in MCHB supported programs        |
|                                   | requiring a referral, who receive |
| **Goal 3: Assure Quality of       | a completed referral.             |
| Care**                            |                                   |
|                                   | **(NOTE: Use Form 9 to report     |
| **(Develop and promote health     | this measure.)**                  |
| services and systems that assure  |                                   |
| appropriate follow-up services)** |                                   |
|                                   |                                   |
| **Level: Grantee**                |                                   |
|                                   |                                   |
| **Category: Women's Health**      |                                   |
+-----------------------------------+-----------------------------------+
| #### GOAL {#goal .unnumbered}     | Increase the number of completed  |
|                                   | referrals for women participating |
|                                   | in MCHB supported programs in     |
|                                   | need of services.                 |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **MEASURE**                       | The number of women participating |
|                                   | in MCHB supported programs        |
|                                   | requiring a referral, who receive |
|                                   | a completed referral.             |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| #### DEF                          | **Numerator:**                    |
| INITION {#definition .unnumbered} |                                   |
|                                   | Unduplicated number of MCHB       |
|                                   | funded program participants who   |
|                                   | have completed service            |
|                                   | referral(s)                       |
+-----------------------------------+-----------------------------------+
|                                   | **Denominator:**                  |
|                                   |                                   |
|                                   | Unduplicated number of MCHB       |
|                                   | funded program participants who   |
|                                   | have a need for which a referral  |
|                                   | was made for health service(s).   |
+-----------------------------------+-----------------------------------+
|                                   | A "completed service referral" is |
|                                   | defined as a client who received  |
|                                   | the services from provider(s) to  |
|                                   | whom she was referred either      |
|                                   | within or outside of the MCHB     |
|                                   | program/agency. The purpose of    |
|                                   | these referrals can be either     |
|                                   | treatment-related (e.g., AIDS or  |
|                                   | substance abuse treatment,        |
|                                   | domestic violence counseling) or  |
|                                   | preventive (e.g., family          |
|                                   | planning, WIC, depression         |
|                                   | screening/ referral, early        |
|                                   | intervention services).           |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| #####  {#section-7 .unnumbered}   | Related to Objective 16.5 :       |
|                                   | Reduce maternal illness and       |
| ##### HEALTHY                     | complications due to pregnancy    |
| PEOPLE 2010 OBJECTIVE {#healthy-p |                                   |
| eople-2010-objective .unnumbered} | Related to Objective 16.17:       |
|                                   | Increase abstinence from alcohol, |
|                                   | cigarettes, and illicit drugs     |
|                                   | among pregnant women.             |
|                                   |                                   |
|                                   | Related to Objective 21.3:        |
|                                   | Increase to at least 95% the      |
|                                   | proportion of pregnant women and  |
|                                   | infants who receive               |
|                                   | risk-appropriate care.            |
+-----------------------------------+-----------------------------------+
| **DATA SOURCE(S) AND ISSUES**     | -   Provider and MCHB program     |
|                                   |     patient records.              |
|                                   |                                   |
|                                   | ```{=html}                        |
|                                   | <!-- -->                          |
|                                   | ```                               |
|                                   | -   Projects will need to have a  |
|                                   |     process to verify a completed |
|                                   |     referral.                     |
+-----------------------------------+-----------------------------------+
| #### SIGNIFI                      | In order to be effective, health  |
| CANCE {#significance .unnumbered} | services must ensure that a       |
|                                   | client's risks are identified and |
|                                   | that they receive services that   |
|                                   | address their identified needs    |
|                                   | and are referred appropriately.   |
|                                   | There is no impact if the         |
|                                   | referral is not                   |
|                                   | completed/services not obtained.  |
+-----------------------------------+-----------------------------------+

**INSTRUCTIONS FOR THE COMPLETION OF FORM 9**

**TRACKING DISCRETIONARY GRANT**

**PERFORMANCE MEASURES**

**#10 and 21**

**General Instructions:**

This form serves two purposes: 1) to show performance measures with a
baseline and annual planned performance objective targets for the
program, and 2) to show the Annual Performance Indicator, progress
actually achieved each year for each performance measure.

**Specific Instructions:**

In the first space under Performance Measure on the form, read the brief
title of the project performance measure that has been selected. For
both national and project measures, in the lines labeled Annual
Performance Indicator, enter the numerical value that expresses the
progress the project has made toward the accomplishment of the
performance objective for the appropriate reporting year.

Complete all required data cells. Please explain computations, where
warranted, in a footnote. If there are numerator and denominator data
for the performance measures, enter those data on the appropriate lines
for the appropriate fiscal year. NOTE: [Do not enter numerator and
denominator data for scale measures.]{.underline}

Repeat this process for each performance measure.

**FORM 9**

**TRACKING DISCRETIONARY GRANT AND TITLE V BLOCK GRANT**

**PERFORMANCE MEASURES**

**[Annual Objective and Performance Data]{.underline}**

  -------------------------------- ------------ ------------ ------------
  **Performance Measure #10**      Baseline     CY\_\_\_\_   CY\_\_\_\_

  ***Degree to which programs have                           
  incorporated cultural                                      
  competence.***                                             

  Annual Performance Objective                               

  Annual Performance Indicator                               

                                                             

  **Performance Measure #21**                                

  ***Percent of women participants                           
  who receive a completed                                    
  referral.***                                               

  Annual Performance Objective                               

  Annual Performance Indicator                               

  Numerator                                                  

  Denominator                                                

                                                             
  -------------------------------- ------------ ------------ ------------

***This page is intentionally left blank.***

[]{#__RefHeading___Toc55379082 .anchor}

APPENDIX C - **REFERENCE LIST**

**Reference List**

1\. Bennett, T. *Women=s health in maternal and child health: Time for a
new tradition?* Maternal and Child Health Journal, 1997; 1: 253-265.

2\. Calle, EE; Rodriguez, C.; Walker-Thurmond, K; Thun, MJ. *Overweight,
obesity, and mortality from cancer in a prospectively studied cohort of
U.S. adults*. The New England Journal of Medicine, 2003; 348.

> 3\. Cesario, SK; *Obesity in Pregnancy: What every nurse needs to
> know*. AWHONN Lifelines, 2003; 7:120 & 122.

4 Collins KS, Shoen C, Joseph S, Duchon L, Simantov E, & Yellowitz, M.
*Health*

*concerns across a woman=s lifespan: The Commonwealth Fund 1998 Survey
of women=s health*. The Commonwealth Fund, May 1999.

5\. Donaldson MS, Yordy KD, Lohr KN, & Vanselow NA, editors. *Primary
care: America=s health in a new era*. Washington, DC: National Academy
Press, 1996.

6\. Finkelstein, EA; Fiebelkorn, IC; and Wang, G. *National medical
spending attributable to overweight and obesity: How much, and who's
paying?* Health Affairs. May 14, 2003.

7\. National Institutes of Health (NIH), National Heart, Lung, and Blood
Institute (NHLBI). *Clinical guidelines on the identification,
evaluation, and treatment of overweight and obesity in adults*. HHS,
Public Health Services (PHS); 1998.

p\. xxiii.

8\. Watkins, ML; Rasmussen, SA; Honein, MA; Botto, LD; and Moore, CA.
*Maternal obesity and risk for birth defects.* Pediatrics, 2003;
111:1152

**APPENDIX D -- STATE TITLE V DIRECTOR -- MATERNAL AND CHILD HEALTH
(MCH) DIRECTORS**

**ALABAMA**

Thomas M. Miller, MD, MPH

Director, Bureau of Family Health Services

Alabama Department of Public Health

P.O. Box 303017

The RSA Tower, Suite 1368

Montgomery, AL 36130-3017

Phone: (334) 206-2940

Fax: (334) 206-2950

Email: <tmiller@adph.state.al.us>

**ALASKA**

Pam Muth, MPH

Chief, Section of Maternal, Child

and Family Health

Alaska Department of Health and

Social Services

3601 C Street, Suite 934

P.O. Box 24029

Anchorage, AK 99524-0249

Phone: (907) 269-3400

Fax: (907) 269-3414

Email: <ptmuth@health.state.ak.us>

**AMERICAN SAMOA**

Jackie Tupa-Talofono

Director, Div. Of Preventive & Environmental Health

Government of American Samoa

Pago Pago, American Samoa 96799

Phone: 9-011-684-633-4606

Fax : 9-011-684-633-5379

Email : <jacki@lbj.peacesat.hawaii.edu>

**ARIZONA**

Jeanette Shea-Ramirez, MS, ACSW

Chief, Office Women=s and Children Health

Arizona Department of Health Services

2927N. 35^th^ Avenue, Suite 300

Phoenix, AZ 85017

Phone: (602) 364-1419

Fax: (602) 364-1464

Email: <jsheara@hs.state.az.us>

**ARKANSAS**

Richard Nugent, MD, MPH

Medical Dir., Family Health Group

Arkansas Department of Health

4815 West Markham, Slot No.41

Little Rock, AR 72205-3867

Phone: (501) 661-2199

Fax: (501) 661-2055

Email: <rnugent@healthyarkansas.com>

**CALIFORNIA**

Susan Steinberg

Interim Chief, Maternal and Child Health

CA State Department of Health Services

714 P Street, Room 708

Sacramento, CA 95814

Phone: (916) 657-1347

Fax: (916) 657-3069

Email: <ssteinbe@dhs.ca.gov>

**COLORADO**

Joan Eden, MSPH, RD

Director, Health Care Program, CSN

Colorado Department of Public Health and Environment

4300 Cherry Creek Drive South

Denver, CO 80246-1530

Phone: (303) 692-2389

Fax: (303) 782-5576

Email: <joan.eden@state.co.us>

**CONNECTICUT**

Martha Okafor

Acting Director, Family Health Division

Connecticut Department of Public

Health

P.O. Box 340308

410 Capitol Avenue - MS 11FHD

Hartford, CT 06134-0308

Phone: (860) 509-8066

Fax: (860) 509-7853

Email: <Martha.Okafor@po.state.ct.us>

**DELAWARE**

Joan Powell, MPA

Director, Family Health Services

DE Division of Public Health

P.O. Box 637, Jesse Cooper Bldg.

Dover, DE 19903

Phone: (302) 739-4785

Fax: (302) 739-6653

Email: <jopowell@state.de.us>

**DISTRICT OF COLUMBIA**

Maralyn Seabrook, MPA

Office of Maternal and Family Health

825 N. Capitol Street, N.W., 3^rd^ Floor

Washington, DC 20002

Phone: (202) 442-9333

Fax: (202) 442-4814

Email: <mseabrook@dchealth.com>

**FLORIDA**

Annette Phelps, ARNP, MSN

Chief, Bureau of Family & Comm. Health

Department of Health, HSF Bin#A13

4052 Bald Cypress Way

Tallahassee, FL 32399-1721

Phone: (850) 254-4100

Fax: (850) 414-6091

Email: <Annette_Phelps@doh.state.fl.us>

**GEORGIA**

Rosalyn Bacon, MPH

Director, DHR/DPH/Family

Health Branch

2 Peachtree Street, N.W. Suite 11-412

Atlanta, GA 30303-3142

Phone: (404) 657-2852

Fax: (404) 657- 7307

Email: <rbacon@dhr.state.ga.us>

**GUAM**

Maggie Murphy-Bell

Administrator, Dept. of Public

Health & Nursing Services

P.O. Box 2816

Hagatna, GUAM 96932

Phone: 9-011-671-735-7110

Fax: 9-011-671-734-7097

Email: <mmbell@dphss.govguam.net>

**HAWAII**

Loretta Fuddy

Chief, Family Health Services Division

HI State Department of Health

1250 Punchbowl St., Rm. 216

Honolulu, HI 96813

Phone: (808) 586-4122

Fax: (808) 586-9303

Email: <loretta.fuddy@fhsd.health.state.hi.us>

**IDAHO**

Russ Duke

Idaho Division of Health

450 West State Street, P.O. Box 83720

Boise, ID 83720-0036

Phone: (208) 334-5930

Fax: (208) 332-7307

Email: <duke@idhw.state.id.us>

**ILLINOIS**

Stephen E. Saunders, MD, MPH

Associate Director, Office of Family Health Department of Human Services

535 West Jefferson Street

Springfield, IL 62702-5058

Phone: (217) 782-2736

Fax: (217) 557-2595

Email: <DHSHP73@dhs.state.il.us>

**INDIANA**

Judith Ganser, MD, MPH

Medical Director, CSHCS/MCH/WIC

Indiana State Department of Health

2 North Meridian Street, Section 7-C

Indianapolis, IN 46204

Phone: (317) 233-1240

Fax: (317) 233-1299

Email: <jganser@isdh.state.in.us>

**IOWA**

Jane Borst, RN, MA

Bureau Chief, Family Services

Iowa Department of Public Health

321 E. 12th St., 5^th^ Floor, Lucas Building

Des Moines, IA 50319-0075

Phone: (515) 281-4911

Fax: (515) 242-6384

Email: <jborst@idph.state.ia.us>

**KANSAS**

Linda Kenney, MPH

MCH Director, Bureau for Children,

Youth and Families

Kansas Dept.of Health and Environment

900 S.W. Jackson, 10^th^ Flr. #1005

Topeka, KS 66612-1274

Phone: (785) 296-1310

Fax: (785) 296-8616

Email: <lkenney@kdhe.state.ks.us>

**KENTUCKY**

Steve Davis, MD

Director, Div. Adult and Child Health

KY Department for Public Health

275 East Main Street

Frankfort, KY 40621

Phone: (502) 564-4830

Fax: (502) 564-8389

Email: <steve.davis@mail.state.ky.us>

**LOUISIANA**

Joan Wightkin, MPH

Administrator, MCH Program

DHH-Office of Public Health

P.O. Box 60630, Room 612

New Orleans, LA 70160

Phone: (504) 568-5073

Fax: (504) 568-8162

[jwightki@dhh.state.la.us](mailto:Jwightki@dhh.state.la.us)

**MAINE**

Valerie J. Ricker, MSN, MS

Director, Family Health Programs

Maine Bureau of Health, Department

of Human Services

State House Station 11

151 Capitol Street

Augusta, ME 04333-0011

Phone: (207) 287-5180

Fax: (207) 287-4631

Email: <valerie.j.ricker@state.me.us>

**MARIANA ISLANDS**

Josephine Sablan

Director, Public Health Commonwealth

Health Center

Dept. of Health-Environmental Services

P.O. Box 409 CK

Saipan, MARI ISLS 96950

Phone: 011-670-234-8950

Fax: 011-670-234-8930

Email: unavailable

**MARSHALL ISLANDS**

Justina Langidrik, MPH

Assistant Secretary, Primary Health Care Ministry of Health &
Environment

P.O. Box 16

Majuro, MARS ISLS 96960

Phone: 011-692-625-3355

Fax: 011-692-625-3432

Email: unavailable

**MARYLAND**

Bonnie Birkel, CRNP, MPH

Director, Center of MCH

MD Department of Health and

Mental Hygiene

201 West Preston Street, Room 318

Baltimore, MD 21201

Phone: (410) 767-6721

Fax: (410) 333-5233

Email: <birkelb@dhmh.state.md.us>

**MASSACHUSETTS**

Sally Fogerty, BSN, MED

Assistant Commissioner

MA Department of Public Health

Bureau of Family and Community Health

250 Washington Street, 5th Floor

Boston, MA 02108-4619

Phone: (617) 624-6090

Fax: (617) 624-6062

Email: <sally.fogerty@state.ma.us>

**MICHIGAN**

Douglas. M. Paterson

Acting Director, Bureau of Children

and Family Programs

MI Department of Public Health

3423 N. Martin L. King, Jr. Blvd.

Rm 218, P.O. Box 30195

Lansing, MI 48909-0195

Phone: (517) 335-9371

Fax: (517) 335-8560

Email: <patersond@michigan.gov>

**MICRONESIA**

Jeff Benjamin, DRPH

MCH Coordinator

FSM Department of HESA

P.O. Box PS 70

Palikir, FM 96941

011-691-320-2619

011-691-320-5263 FAX

**MINNESOTA**

Jan Jernell, MPH

Director, Division of Family Health

MN Department of Health

P.O. Box 64882

St. Paul, MN 55164-8953

Phone: (651) 281-9883

Fax: (651) 215-8953

Email: <jan.jernell@health.state.mn.us>

**MISSISSIPPI**

Dave Beck, MPPA

Director, MS State Department of Health

570 E. Woodrow Wilson

Jackson, MS 39216

Phone: (601) 960-7472

Fax : (601) 960-7825

Email : <dbeck@msdh.state.ms.us>

**MISSOURI**

Paula Nickelson

Div. Dir. Of Maternal, Child & Family Hlth

Missouri Department of Health

930 Wildwood Drive, PO Box 570

Jefferson City, MO 65102-0570

Phone: (573) 751-6174

Fax: (573) 526-5348

Email: <nickep@dhss.state.mo.us>

**MONTANA**

JoAnn Walsh Dotson, MSN, RN

Chief, Family & Community Hlth Bureau

MT Department of Public Health

and Human Services

P.O. Box 202951

1400 Broadway

Helena, MT 59620

Phone: (406) 444-4743

Fax: (406) 444-2606

Email: <jdotson@state.mt.us>

**NEBRASKA**

Paula Eurek

Administrator, Division of Family Health

Nebraska Dept. of Health and Human Services

301 Centennial Mall South

P.O. Box 95044

Lincoln, NE 68509-5044

Phone: (402) 471-0196

Fax: (402) 471-7049

Email: <paula.eurek@hhss.state.ne.us>

**NEVADA**

Judy Wright

Bureau Chief, Family Health

Services Bureau

NV State Health Division

505 East King Street, Room 200

Carson City, NV 89701-4792

Phone: (775)684-4285

Fax: (702) 684-4245

Email: <jwright@nvhd.state.nv.us>

**NEW HAMPSHIRE**

Joan H. Ascheim, MSN

Chief, Bureau of MCH

NH Department of Health and

Human Services

6 Hazen Drive

Concord, NH -3301-6527

Phone: (603) 271-4516

Fax: (603) 271-3827

Email: <jascheim@dhhs.state.nh.us>

**NEW JERSEY**

Celeste Androit Wood, MA

Assistant Commissioner, Family

Health Services

NJ State Department of Health and

Senior Services

P.O. Box 364, 50 East State Street

Trenton, NJ 08625-0364

Phone: (609) 292-4043

Fax: (609) 292-9599

Email: <celeste.androit-wood@doh.state.nj.us>

**NEW MEXICO**

Jane Peacock

Bureau Chief

NM Department of Health/PHD, Family Health Bureau

525 Camino des los Marquez, Suite 6

Sante Fe, NM 87501

Phone: (505) 476-8589

Fax : (505) 476-8512

Email : <janep@doh.state.nm.us>

**NEW YORK**

Nancy Wade

MCH Director

Director, Div. of Family Health

NY State Department of Health

Corning Tower Building, Room 890

Albany, NY 12237-0612

Phone: (518) 473-7922

Fax: (518) 473-2015

Email: <naw02@health.state.ny.us>

**NORTH CAROLINA**

Kevin Ryan, MD, MPH

Chief, Women=s & Children=s

Health Section

NC DHHS-Division of Public Health

1916 Mail Service Center

Raleigh, NC 27699-1916

Phone: 919) 715-7932

Fax: (919) 715-3925

Email: <Kevin.ryan@ncmail.net>

**NORTH DAKOTA**

Sandra Anseth, RN, BSN

Director, MCH

ND Department of Health

600 East Boulevard Avenue, Dept. 301

Bismarck, ND 58505-0200

Phone: (701) 328-4532

Fax: (702) 328-1412

Email: <sanseth@state.nd.us>

**OHIO**

David P. Schor

Division Chief, Div. of Family & Community

Health Services

OH Department of Health

246 North High Street, P.O. Box 118

Columbus, OH 43216-0118

Phone: (614) 466-3263

Fax: (614) 728-3616

Email: <Dschor@gw.odh.state.oh.us>

**OKLAHOMA**

Suzanna Dooley

Chief, Maternal & Child Health Services

Oklahoma State Department of Health

1000 N.E., 10th Street

Oklahoma City, OK 73117-1299

Phone: (405) 271-4480

Fax: (405) 271-3632

Email: <Suzannad@health.state.ok.us>

**OREGON**

Donalda Dodson

Acting Assistant Administrator

OR Health Division

800 NE Oregon Street, Suite 850

Portland. OR 97232

Phone: (503) 731-4398

Fax: (503) 731-4083

Email: <donala.Dodson@state.or.us>

**PALAU**

Caleb Tyn. Otto, MBBS, MHA

Director, Bureau of Public Health Services

Ministry of Health

P.O. Box 6027

Koror, Palau 96940

Phone: 9-011-680-488-3116

Fax: 9-011-680-488-3115

Email: <phpal@palaunet.com>

**PENNSYLVANIA**

Sarah Baker

Director, Bureau of Family Health

Pennsylvania Department of Health

H&W Building, Rm 733, P.O. Box 90

Harrisburg, PA 17108

Phone: (717) 787-7192

Fax: (717) 772-0323

Email: <Sbaker@state.pa.us>

**PUERTO RICO**

Roberto Varela-Flores, MD, MPH

MCH Director

Puerto Rico Department of Health

P.O. Box 70184

San Juan, PR 00936-8184

Phone: 787) 274-5678

Fax: (787) 274-5523

Email: <rvarela@salud.gov.pr>

**RHODE ISLAND**

William Hollinshead, MD, MPH

Medical Director, Division of Family Health

RI Department of Health

Three Capitol Hill, Room 302

Providence, RI 02908-5097

Phone: (401) 222-4655

Fax: (401) 222-1442

Email: <billh@doh.state.ri.us>

**SOUTH CAROLINA**

Sarah Balcereck, M.S.N.

Director, MCH/DHEC

1751 Calhoun Street

P.O. Box 101106

Columbia, SC 29211

Phone: (803) 898-0807

Fax: (803) 898-0557

Email: <balcersw@dhec.sc.gov>

**SOUTH DAKOTA**

Kayla Tinker

Administrator, Office of Family Health

SD Department of Health

615 East 4^th^ Street

Pierre, SD 57501-3185

Phone: (605) 773-3737

Fax: (605) 773-5942

Email: <Kayla.tinker@state.sd.us>

**TENNESSEE**

Margaret Major

Director, MCH

TN Department of Health

425 5^th^ Avenue, N., 5th Floor

Nashville, TN 37247-4701

Phone: (615) 741-0377

Fax: (615) 741-1063

Email: <margaret.major@state.tn.us>

**TEXAS**

Fouad Berrahou

Director, Title V Program

TX Department of Health

1100 W. 49^th^ Street

Austin, TX 78756-3199

Phone: (512) 458-7321

Fax: (512) 458-7358

Email: <Fouad.Berrahou@tdh.state.tx.us>

**UTAH**

Nan Streeter, RN, MS

Utah Department of Health

P.O. Box 142001

Salt Lake City, UT 84114-2001

Phone: (801) 538-6869

Fax: (801) 538-9409

Email: <nanstreeter@utah.gov>

**VERMONT**

Donald Swartz

Director, MCH, Division of Health Improv.

Vermont Dept. of Health

108 Cherry Street, P.O. Box 70

Burlington, VT 05402

Phone: (802) 847-5225

Fax: (802) 8637270

Email: <dswartz@vdh.state.vt.us>

**VIRGINIA**

Janice Hicks

Office of Family Health Services

1500 East Main Street, Suite 104

Richmond, VA 23219

Phone: (804) 371-4125

Fax: (804) 692-0184

Email: <jhicks@vdh.state.us>

**VIRGIN ISLANDS**

Mavis Matthew

Acting Commissioner of Health

Department of Health

3012 Vitraco Mall. Estate Golden Rock

Cristiansted St. Croix, VI 00820-4320

Phone: (340) 713-9924

Fax: (340) 713-9928

Email: <vidohmlm@earth.link.net>

**WASHINGTON**

Rita Schmidt

Director, Maternal and Child Health

WA State Department of Health

Community and Family Health

P.O. Box 47835

Olympia, WA 98504-7835

Phone: (360) 236-3581

Fax: (360) 236-2323

Email: <rita.Schmidt@doh.wa.gov>

**WEST VIRGINIA**

Patricia Moss, MSW, LCSW

Director, Office of MCH

Bureau for Public Health

Department of Health & Human Resources

350 Capitol Street, Room 427

Charleston, WV 25301-3714

Phone: (304) 558-5388

Fax: (304) 558-4984

Email: <patmoss@wvdhhr.org>

**WISCONSIN**

Murray Katcher

Chief, Family and Community Health Bureau

Wisconsin Division of Health

One West Wilson Street, Room 243

Madison, WI 53702

Phone: (608) 266-5818

Fax: (608) 266-3125

Email: <katchml@dhfs.state.wi.us>

**WYOMING**

Phyllis Sherard

MCH Manager, Division of Public Health

WY Department of Health

Hathaway Building, 4^th^ Floor, Rm. 465 Cheyenne, WY 82002

Phone: (307) 777-7942

Fax: (307) 777-7215

Email: <pshera@state.wy.us>

#   {#section-8 .unnumbered}

# APPENDIX E -- DHHS, OFFICE ON WOMEN'S HEALTH, REGIONAL WOMEN'S HEALTH COORDINATORS FY 2006

**Region I- CT, MA, ME, NH, RI, VT**

Laurie Robinson, M.T.S.

Women=s Health Coordinator

John F. Kennedy Federal Bldg. Room 2126

Boston, MA 02203

\(617\) 565-1071 FAX (617) 565-4265

[Lrobinson@hrsa.gov]{.underline}

**Region II- NJ, NY, PR, Virgin Islands**

Sandra Estepa, M.S.

Women\'s Health Coordinator

26 Federal Plaza, Room 3835

New York, NY 10278

\(212\) 264-4628 FAX (212) 264-1324

[sestepa@hrsa.gov]{.underline}

**Region III- DC, DE, MD, PA, VA, WV**

Rosa F. Myers, A.R.N.P., M.S.N.

Women\'s Health Coordinator

150 S. Independence Mall West, Ste. 436

Philadelphia, PA 19106-3499

\(215\) 861-4637 FAX (215) 861-4623

[rmyers@hrsa.gov]{.underline}

**Region IV- AL, FL, GA, KY, MS, NC, SC, TN**

Annie Brayboy Fair, M.P.H., M.S.W.

Women=s Health Coordinator

61 Forsyth St., S.W., 5B95

Atlanta, GA 30303-8909

\(404\) 562-7904 FAX (404) 562-7899

[afair@osophs.dhhs.gov]{.underline}

**Region V- IL, IN, MI, MN, OH, WI**

Michelle Hoersch, M.S.

Women\'s Health Coordinator

233 N. Michigan Avenue, Suite 1300

Chicago, IL 60601

\(312\) 353-8122 FAX (312) 353-7800

[mhoersch@osophs.dhhs.gov]{.underline}

**Region VI- AR, LA, NM, OK, TX**

Charlotte Gish, C.N.M.

Women\'s Health Coordinator

1301 Young Street, Suite 1124

Dallas, TX, 75202

\(214\) 767-3482 FAX (214) 767-3209

[cgish@osophs.dhhs.gov]{.underline}

**Region VII- IA, KS, MO , NE**

Joyce Townser, R.N., B.S.N.

Women\'s Health Coordinator

601 East 12th Street, Room 210

Kansas City, MO 64106

\(816\) 426-2926 FAX (816) 426-2178

[jtownser@hrsa.gov]{.underline}

**Region VIII- CO, MT, ND, SD, UT, WY**

Laurie Konsella, M.P.A.

Women\'s Health Coordinator

1961 Stout Street, Room 498

Denver, CO 80294-3538

\(303\) 844-7854 FAX (303) 844-2019

[lkonsella@hrsa.gov]{.underline}

**Region IX- AZ, CA, HI, NV, American Samoa,**

**Guam, Marshall Islands, Micronesia, Northern Mariana Islands, Palau**

Kay A. Strawder, J.D., M.S.W.

Women\'s Health Coordinator

50 United Nations Plaza, Room 327

San Francisco, CA 94102

\(415\) 437-8119 FAX (415) 437-8004

[kstrawder@osophs.dhhs.gov]{.underline}

**Region X- AK, ID, OR, WA**

Marian Mehegan, D.D.S., M.P.H.

Women\'s Health Coordinator

2201 Sixth Avenue, M/S RX-29

Seattle, WA 98121

\(206\) 615-2024 FAX (206) 615-2481

[mmehegan@hrsa.gov]{.underline}

***This page is intentionally left blank.***

**APPENDIX F -- DHHS, OFFICE OF POPULATION AFFAIRS, FAMILY PLANNING
(TITLE X) REGIONAL PROGRAM CONSULTANTS, FY 2006**

**Region I**

Kathleen Stratford

Public Health Advisor)

JFK Federal Building, Room 2126

Boston, MA 02203

ph: 617-565-1070,

fx: 617-565-4265

<kstratford@osophs.dhhs.gov>

CT, ME, MA, NH, RI, VT

**Region II**

Robin Lane

26 Federal Plaza, Room 38-100

New York, NY 10278

ph: 212-264-3935

fx: 212-264-9908

<rlane@osophs.dhhs.gov>

NJ, NY, PR, VI

**Region III**

Donna Garner (Co-RPC)

<dgarner@osophs.dhhs.gov>

ph: 215-861-4624

D. Lynn Gronseth, M.P.H. (Co-RPC)

<dlgronseth@osophs.dhhs.gov>

ph: 215-861-4656

The Public Ledger Bldg.,

Ste. 426

150 S. Independence Mall West

Philadelphia, PA 19106-3499

fx: 215-861-4623

DE, D.C., MD, PA, VA, WV

**Region IV**

Cristino Rodriguez

Atlanta Federal Center

61 Forsyth Street, S.W.,

Ste. 5B95

Atlanta, GA 30303-8909

ph: 404-562-7900

fx: 404-562-7899

<crodriguez@osophs.dhhs.gov>

KY, MS, NC, TN, AL, FL, GA, SC

**Region V**

Janice Ely

233 North Michigan Avenue

Suite 1300

Chicago, IL 60601

ph: 312-886-3864

fx: 312-353-7800

<jely@osophs.dhhs.gov>

IL, IN, MI, MN, OH, WI

**Region VI**

Evelyn Glass

1301 Young Street, Suite 1124

Dallas, TX 75202

ph: 214-767-3088

fx: 214-767-3425

<eglass@osophs.dhhs.gov>

AR, LA, NM, OK, TX

**Region VII**

Elizabeth Curtis

Federal Office Building

Room S1800

601 East 12th Street

Kansas City, MO 64106

ph: 816-426-2924

fx: 816-426-2178

<ecurtis@osophs.dhhs.gov>

IA, KS, MO, NE

**Region VIII**

Jill Leslie

Federal Building, 4th Floor

1961 Stout Street

Denver, CO 80294-3538

ph: 303-844-7856

fx: 303-844-2019

<jleslie@osophs.dhhs.gov>

CO, MT, ND, SD, UT, WY

**Region IX**

Nancy Mautone-Smith

50 United Nations Plaza

San Francisco, CA 94102

ph: 415-437-7984

fx: 415-437-8004

<nmautone-smith@osophs.dhhs.gov>

AZ, CA, HI, NV, and the six U.S.

Associated Pacific jurisdictions

**Region X**

Janet Wildeboor

2201 Sixth Avenue, M/S RX-29

Room 800

Seattle, WA 98121-2500

ph: 206-615-2776

fx: 206-615-2481

<jwildeboor@osophs.dhhs.gov>

AK, ID, OR, WA