Building State Capacity for Integration Learning Collaborative Project Application Survey

Instructions
The applicant must be a state oral health program or state oral health coalition (only one application will be accepted per state). Read the project overview for details about eligibility, requirements, and benefits of participation.

Team lead: Complete this application and affirm commitment via SurveyMonkey. At least three other members from the state health department or another state agency or organization (e.g., state oral health program, chronic disease program, Medicaid agency, oral health coalition, Title V Maternal and Child Health program) must be selected to form a core project team to participate in the learning collaborative (LC).
Core project team members: Each core project team member must complete their own SurveyMonkey form to affirm commitment to participate in LC webinars and coaching calls and to allocate time to meet with the team.
The team lead application plus at least three core project team commitment affirmations member applications must be completed in Survey Monkey by 11:59 p.m. ET on Wednesday, July 1, 2026.
Contact Sarah Kolo, sk22@georgetown.edu, for assistance.

1.State Oral Health Program or State Oral Health Coalition Lead(Required.)

Name, credentials:

Organization (agency/bureau) name:

Program (department/office) name:

Title:

E-mail address:

Phone number:

2.Core Project Team Member 2 (required)(Required.)

Name, credentials:

Organization name:

Title:

E-mail address:

Phone number:

3.Core Project Team Member 3 (required)(Required.)

Name, credentials:

Organization name:

Title:

E-mail address:

Phone number:

4.Core Project Team Member 4 (required)

Name, credentials:

Organization name:

Title:

E-mail address:

Phone number:

5.Core Project Team Member 5 (optional)

Name, credentials:

Organization name:

Title:

E-mail address:

Phone number:

6.Core Project Team Member 6 (optional)

Name, credentials:

Organization name:

Title:

E-mail address:

Phone number:

Please answer each prompt in 250 words or less. We strongly encourage you to answer these questions as a team and to describe unique/differing perspectives of team members, when possible.

7.Why is integrating oral health care and prenatal care an important strategy to improve access to oral health care in your state?(Required.)

8.Describe an activity or program your organization participated in during the past 3 years focused on integrating oral health care and prenatal care in your state. Why was it successful, and what barriers did you experience?(Required.)

9.Describe how your organization has worked collaboratively with other state partners to improve access to oral health care for pregnant women (e.g., state oral health program, chronic disease program, Medicaid agency, oral health coalition, Title V MCH program). Provide examples of strengths and opportunities that have emerged from these collaborations.(Required.)

10.Describe at least one strength in your state that facilitates integrating oral health care and prenatal care (e.g., access to data, favorable Medicaid benefits, scope of practice that allows medical professionals to deliver oral health care).(Required.)

11.What do you hope to learn and accomplish by participating in this project?(Required.)

Selected applicants will be asked to submit a detailed budget for $20,000 for October 2026 through June 2027 and $40,000 for July 2027 through January 2028. Funds cannot be used to purchase alcohol, entertainment, equipment, gift cards, or tobacco.

12.I’ve read the project overview and required activities and agree to participate fully in the learning collaborative. (Type name and date.)(Required.)

This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an annual award totaling $1,700,000 with no funding from nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, or endorsement by, HRSA, HHS, or the U.S. government. For more information, please visit www.HRSA.gov.