2022-23 DSME Mini-Grant Application Question Title * 1. Applicant Information Organization Name Organization Address Website Address Contact Name Contact Title County Headquarters Email Address Contact Phone Number Question Title * 2. What type of agency is your organization? For-profit Non-profit Government (this grant cannot fund county DOHs, please contact state office for funding opportunities) Question Title * 3. How did you find out about this funding opportunity? Question Title * 4. What population does (or will )your DSME program serve? (Please note, this funding is for DSME programs serving adults ONLY.) Adults Children Both adults and children Question Title * 5. List the counties where your organization currently provides DSME (whether or not they are recognized or accredited), the counties where you plan to provide DSME, and counties where you propose to increase access to people with physical or intellectual disabilities. Counties currently served: Counties you plan to serve: Counties where you propose to increase access to people with physical or intellectual disabilities: Question Title * 6. What is the current status of your DSME program? (check what applies to you) Currently do not offer diabetes education services Offer diabetes education services, but not DSME Offer DSME, but program is not accredited or recognized Offer DSME and program is accredited or recognized Question Title * 7. How long have you provided diabetes education services? Question Title * 8. Describe your organization’s knowledge and experience with providing diabetes education services. Question Title * 9. How do you [will you] provide your services? (check all that apply) In person Telehealth To individuals In Group settings Question Title * 10. Please describe any gaps in existing services or special populations that your program helps [will help] to serve. Next