This program is specifically designed for Diabetes Self-Management Education and Support (DSMES) ONLY. This is not intended to support Diabetes Prevention Programs (DPP).

We can NOT support any agency receiving 2320 Diabetes grant money or any County Health Department.

*1.Applicant Information(Required.)

Organization Name

Organization Address

Website Address

Contact Name

Contact Title

County Headquarters 

Email Address

Contact Phone Number

*2.What type of agency is your organization?(Required.)

For-profit

Non-profit

Government (this grant cannot fund county DOHs, please contact state office for funding opportunities)

3.How did you find out about this opportunity?

*4.What population can receive (or will) DSMES from your program? (Please note, this opportunity is for DSMES services serving adults ONLY.)(Required.)

Adults (18 years of age and older)

Children (0-17 years of age)

Both adults and children 

*5.List the counties where your organization currently provides DSMES (whether or not they are recognized or accredited) and the counties where you plan to provide DSMES.(Required.)

Counties currently served:

Counties you plan to serve:

*6.What is the current status of your DSMES Service? (check what applies to you)(Required.)

Currently do not offer diabetes education services

Offer diabetes education services, but not DSMES

Offer DSMES, but program is not accredited or recognized

Offer DSMES and program is accredited or recognized

*7.How long have you provided diabetes education services?(Required.)

*8.Experience: Describe your organization’s knowledge and experience with providing diabetes education services. If you have an existing DSMES program or any existing diabetes services. Please describe those services and your program.(Required.)

*9.Project Overview: Please describe what you would hope to accomplish from participating in this program. How might a mentor and technical assistance help you achieve your goals?(Required.)

10.Project Justification: How would this help the people you serve? What are the gaps you would be filling?

*11.How do you [will you] provide your services? (check all that apply)(Required.)

In person

Telehealth

To individuals

In Group settings

*12.How does your current program adjust the delivery of the DSMES programs to mitigate hindrance to enrollment and retention? How would you support enrollment and retention? (Examples include ease of wheelchair access, covered portico, sign language interpreter provided, participation of additional support personnel/caregivers, extended class sessions, adaptive education materials, or technology aids.)(Required.)

*13.Does your organization currently (or within the last year) bill any of the following:(Required.)

Medicaid

Medicare

Private insurance for any services

Other payer sources