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* 1. Applicant Information

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* 2. What type of agency is your organization?

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* 3. How did you find out about this funding opportunity?

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* 4. What population does (or will )your DSME program serve? (Please note, this funding is for DSME programs serving adults ONLY.)

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* 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.

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* 6. What is the current status of your DSME program? (check what applies to you)

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

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* 8. Describe your organization’s knowledge and experience with providing diabetes education services.

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

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* 10. Please describe any gaps in existing services or special populations that your program helps [will help] to serve.

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