DSMES Partner Site-Level Rapid Evaluation Nomination

Form Approved

OMB No. 0920-xxxx

Exp. Date XX/XX/20XX

DSMES Site-Level Rapid Evaluation - Site Nomination Form

Please use this form to nominate two (2) initiatives/programs within your state for inclusion in the site-level rapid evaluation as part of the national evaluation of DP18-1815

Your participation is voluntary. You may skip any question you do not want to answer for any reason. There are no known risks or direct benefits to you for completing this nomination form. The information you provide will help inform the selection of DSMES sites for the site-level rapid evaluation.  

Note: Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-19BHC)

NOMINATION GUIDANCE:

Please nominated two (2) initiatives/programs that:

• Are working to provide DSMES services to people with diabetes

• Have either full or pending ADA-recognition/ADCES-accreditation

• Are either new or established programs/sites, including affiliate and community sites

• Are offered at pharmacies but may not currently be ADA-recognized/ADCES-accredited
  
  

The unit of analysis for the rapid evaluation is the site. If your health department works with an organization or program offering CDC-recognized LCPs at multiple sites, please indicate a specific site to be included in the rapid evaluation. 

Consider selecting sites that have different characteristics, such as:

• Different delivery platforms -- In-person vs. combination

• Serve different population groups--focus on Medicaid population vs. focus on African American population

• Located in different geographic areas--urban vs. rural

• History of performance--strong performance vs. experienced many challenges 
  
  

Your nominations will be reviewed by a CDC panel to ensure sites meet the eligibility criteria. The Deloitte National Evaluation Team will send follow up communication to confirm the inclusion of your nominated sites or request additional clarifying information. 

The nomination form will take approximately 30 minutes to complete. Nominations must be submitted no later than Month Day

Additional information about site participation in the rapid evaluation is available in the 1815 Site-Level Rapid Evaluation FAQs. Contact 1815evaluation@deloitte.com if you have any questions about this nomination form or the rapid evaluations. 

CLICK NEXT TO COMPLETE THE NOMINATION FORM

(End of Page 1)

Health Department Information

Nominator's Name
The nominator is the person completing this form.

Nominator's Name  ________________________________________

Position/Job Title ________________________________________

Phone ________________________________________

Email ________________________________________

Organization Name ________________________________________

City ________________________________________

Zip Code ________________________________________

(End of Page 2)

1st Nominee: Initiative/Program Contact Information 

Name of initiative/program ________________________________________

List the county(ies) where the initiative/program is being implemented

______________________________________________________________

______________________________________________________________

______________________________________________________________

Complete the contact information below for the DSMES initiative/program that you are nominating for the rapid evaluation. 

Street Address (for the specific site where the initiative/program is being offered) ________________________________________

City ________________________________________

Zip Code ________________________________________

Site ID/Organization Code ________________________________________

Primary Contact Person

Primary Contact Person Name ________________________________________

Position/Job Title ________________________________________

Phone ________________________________________

Email ________________________________________

Agency/Organization ________________________________________

Alternate Contact Person

Alternative Contact Person Name ________________________________________

Position/Job Title ________________________________________

Phone  ________________________________________

Email ________________________________________

Agency/Organization ________________________________________

Is your health department currently supporting this initiative/program site through 1815 funds?

• Yes, we are currently supporting this initiative/program through 1815 funds

• No, we are in the process of establishing a contract with this initiative/program

• No, but we are expecting to support this initiative/program in the future years of the cooperative agreement

• Other, please specify ____________________

• I don't know

(End of Page 3)

1st Nominee: Initiative/Program Information 

Please answer the following questions to provide some contextual information about the nominated initiative/program.

What setting does the initiative/program operate in? 

• State Government

• Community-based organization

• Faith-based organization

• Pharmacy

• Healthcare organization

• Public employer worksite

• Private employer worksite

• Other, please specify ____________________

• I don't know

Indicate whether the initiative/program provides targeted services to specific populations by answering the questions below

Does the initiative/program have a specific focus on serving any of the following age group(s)? (select all that apply)

• The initiative/program does not have a specific focus on any age group

• Adults 20-24

• Adults 25-39

• Adults 40-49

• Adults 50-64

• Adults 65 & Older

• Other age group, please specify ____________________

• I don't know

Does the initiative/program have a specific focus on serving Hispanics/Latinos? 

• Yes

• No

• I don't know

Does the initiative/program have a specific focus on serving the following populations? (Select all that apply)

• The initiative/program does not have a specific focus on any racial group

• African American or Black

• White

• American Indian or Alaska Native

• Asian Indian

• Chinese

• Filipino

• Japanese

• Korean

• Vietnamese

• Other Asian, please specify ____________________

• Native Hawaiian or Other Pacific Islander

• Guamanian or Chamorro

• Samoan

• Other, please specify ____________________

• I don't know

Does the initiative/program have a specific focus on serving any of the following sub-populations? (select all that apply)

• The initiative/program does not have a specific focus on any other sub-population

• Low socioeconomic status

• People with disabilities, including mental health issues

• Medicaid populations

• Other sub-populations, please specify: ____________________

• I don't know

What is the primary geographic region that the initiative/program serves? (Select only one)  

• Urbanized Area (population greater than 50,000)

• Urbanized Cluster (population greater than 2,500 less than 50,000)

• Rural Areas (all areas not included within an urban area)

• Other geographic area, please specify: ____________________

• I don't know

(End of Page 4)

1st Nominee: Health Department Collaboration with Initiative/Program

To your knowledge, how long has the initiative/program been providing diabetes self-management education and support to people with diabetes? 

____________________

long has your health department been supporting this initiative/program, through CDC funding?

______________________________________________________________

______________________________________________________________

______________________________________________________________

Will your health department be collecting any data from this initiative/program for the 1815 recipient-led evaluation?

• Yes

• No

• I don't know

Has this initiative/program participated in previous data collection efforts with your state health department?

• Yes

• No

• I don't know

(End of Page 5)

Please specify when the evaluation was conducted (mo/yr) 

Month  ________________________________________

Year  ________________________________________

Please describe the focus of the evaluation

______________________________________________________________

______________________________________________________________

______________________________________________________________

(End of Page 6)

1st Nominee: Health Department Collaboration with Initiative/Program, continued

Health Department Support - How is the Health Department supporting this initiative/program through 1815-funds? (e.g. support organizations in obtaining ADA-recognition/ADCES-accreditation, marketing for DSMES, provider education on referrals to DSMES, sponsor pharmacists training in DSMES) 

______________________________________________________________

______________________________________________________________

______________________________________________________________

Which 1815-funded Category A strategies align with the support your health department is providing to this initiative/program? (select all that apply)

• A1: Improve access to and participation in ADA-recognized/ADCES-accredited DSMES program in underserved areas

• A2: Expand or strengthen DSMES coverage policy

• A3: Increase engagement of pharmacist in the provision of DSMES or Medication Management

• A4: Assist HCOs to identify people with prediabetes and refer them to CDC-recognized lifestyle change programs

• A5: Expand availability of National DPP as a covered benefit

• A6: Increase enrollment in CDC-recognized lifestyle change programs

• A7: Develop infrastructure to promote long-term sustainability/reimbursement for Community Health Workers (CHWs)

Please list any organizations you are collaborating with to support implementation of 1815-funded activities within this initiative/program (e.g. community-based organizations, contracted agencies, health care organizations). If you do not work with any partners, enter "N/A" in the first row. 

Organization Name	Organization Type (e.g. Health Care, Community-Based, Faith-Based)
1.	1.
2.	2.
3.	3.
4.	4.
5.	5.

Has your health department previously supported this initiative/program through another funding mechanism beyond 1815 (e.g. DP13-1305, DP14-1422, state budget, other)? (select all that apply) 

• No, our health department has not previously supported this initiative/program through another funding mechanism

• We supported this initiative/program through DP13-1305

• We supported this initiative/program through DP14-1422

• We supported this initiative/program through state funding

• Other support, please specify all other funding sources that previously supported this initiative/program: ____________________

• I don't know

Is your health department currently supporting this initiative/program site through a funding mechanism beyond 1815 (e.g. DP18-1817, WISEWOMAN, state budget, other)? (select all that apply)

• No, our health department does not currently support this initiative/program through another funding mechanism

• We support this initiative/program through DP18-1817

• We support this initiative/program through state funding

• Other support, please specify all other funding sources to support this initiative/program: ____________________

• I don't know

Please specify and describe how else you work with this initiative/program?

______________________________________________________________

______________________________________________________________

______________________________________________________________

Why have you nominated this initiative/program for inclusion in the site-level rapid evaluation?

______________________________________________________________

______________________________________________________________

______________________________________________________________

What other information would you like to share about this initiative/program?

______________________________________________________________

______________________________________________________________

______________________________________________________________

(End of Page 7)

Thank you for completing the first of two DSMES nominations for site-level rapid evaluations. Click next to submit the second nomination.

(End of Page 8)

2nd Nominee: Initiative/Program Contact Information 

Name of initiative/program ________________________________________

List the county(ies) where the initiative/program is being implemented

______________________________________________________________

______________________________________________________________

______________________________________________________________

Complete the contact information below for the DSMES initiative/program that you are nominating for the rapid evaluation. 

Street Address (for the specific site where the initiative/program is being offered) ________________________________________

City ________________________________________

Zip Code ________________________________________

Site ID/Organization Code ________________________________________

Primary Contact Person

Primary Contact Person Name ________________________________________

Position/Job Title ________________________________________

Phone ________________________________________

Email ________________________________________

Agency/Organization ________________________________________

Alternate Contact Person

Alternative Contact Person Name ________________________________________

Position/Job Title ________________________________________

Phone  ________________________________________

Email ________________________________________

Agency/Organization ________________________________________

Is your health department currently supporting this initiative/program site through 1815 funds?

• Yes, we are currently supporting this initiative/program through 1815 funds

• No, we are in the process of establishing a contract with this initiative/program

• No, but we are expecting to support this initiative/program in the future years of the cooperative agreement

• Other, please specify ____________________

• I don't know

(End of Page 9)

2nd Nominee: Initiative/Program Information 

Please answer the following questions to provide some contextual information about the nominated initiative/program.

What setting does the initiative/program operate in?

• State Government

• Community-based organization

• Faith-based organization

• Pharmacy

• Healthcare organization

• Public employer worksite

• Private employer worksite

• Other, please specify ____________________

• I don't know

Indicate whether the initiative/program provides targeted services to specific populations by answering the questions below 

Does the initiative/program have a specific focus on serving any of the following age group(s)? (select all that apply)

• The initiative/program does not have a specific focus on any age group

• Adults 20-24

• Adults 25-39

• Adults 40-49

• Adults 50-64

• Adults 65 & Older

• Other age group, please specify ____________________

• I don't know

Does the initiative/program have a specific focus on serving Hispanics/Latinos? 

• Yes

• No

• I don't know

Does the initiative/program have a specific focus on serving the following populations? (Select all that apply)

• The initiative/program does not have a specific focus on any racial group

• African American or Black

• White

• American Indian or Alaska Native

• Asian Indian

• Chinese

• Filipino

• Japanese

• Korean

• Vietnamese

• Other Asian, please specify ____________________

• Native Hawaiian or Other Pacific Islander

• Guamanian or Chamorro

• Samoan

• Other, please specify ____________________

• I don't know

Does the initiative/program have a specific focus on serving any of the following sub-populations? (select all that apply)

• The initiative/program does not have a specific focus on any other sub-population

• Low socioeconomic status

• People with disabilities, including mental health issues

• Medicaid populations

• Other sub-populations, please specify: ____________________

• I don't know

What is the primary geographic region that the initiative/program serves? (Select only one)  

• Urbanized Area (population greater than 50,000)

• Urbanized Cluster (population greater than 2,500 less than 50,000)

• Rural Areas (all areas not included within an urban area)

• Other geographic area, please specify: ____________________

• I don't know

(End of Page 10)

2nd Nominee: Health Department Collaboration with Initiative/Program

To your knowledge, how long has the initiative/program been providing diabetes self-management education and support to people with diabetes? 

____________________

How long has your health department been supporting this initiative/program, through CDC funding?

______________________________________________________________

______________________________________________________________

______________________________________________________________

Will your health department be collecting any data from this initiative/program for the 1815 recipient-led evaluation?

• Yes

• No

• I don't know

Has this initiative/program participated in previous data collection efforts with your state health department?

• Yes

• No

• I don't know

(End of Page 11)

Please specify when the evaluation was conducted (mo/yr) 

Month  ________________________________________

Year  ________________________________________

Please describe the focus of the evaluation

______________________________________________________________

______________________________________________________________

______________________________________________________________

(End of Page 12)

2nd Nominee: Health Department Collaboration with Initiative/Program, continued

Health Department Support - How is the Health Department supporting this initiative/program through 1815-funds? (e.g. support organizations in obtaining ADA-recognition/ADCES-accreditation, marketing for DSMES, provider education on referrals to DSMES, sponsor pharmacists training in DSMES) 

______________________________________________________________

______________________________________________________________

______________________________________________________________

Which 1815-funded Category A strategies align with the support your health department is providing to this initiative/program? (select all that apply)

• A1: Improve access to and participation in ADA-recognized/ADCES-accredited DSMES program in underserved areas

• A2: Expand or strengthen DSMES coverage policy

• A3: Increase engagement of pharmacist in the provision of DSMES or Medication Management

• A4: Assist HCOs to identify people with prediabetes and refer them to CDC-recognized lifestyle change programs

• A5: Expand availability of National DPP as a covered benefit

• A6: Increase enrollment in CDC-recognized lifestyle change programs

• A7: Develop infrastructure to promote long-term sustainability/reimbursement for Community Health Workers (CHWs)

Please list any organizations you are collaborating with to support implementation of 1815-funded activities within this initiative/program (e.g. community-based organizations, contracted agencies, health care organizations). If you do not work with any partners, enter "N/A" in the first row. 

Organization Name	Organization Type (e.g. Health Care, Community-Based, Faith-Based)
1.	1.
2.	2.
3.	3.
4.	4.
5.	5.

Has your health department previously supported this initiative/program through another funding mechanism beyond 1815 (e.g. DP13-1305, DP14-1422, state budget, other)? (select all that apply) 

• No, our health department has not previously supported this initiative/program through another funding mechanism

• We supported this initiative/program through DP13-1305

• We supported this initiative/program through DP14-1422

• We supported this initiative/program through state funding

• Other support, please specify all other funding sources that previously supported this initiative/program: ____________________

• I don't know

Is your health department currently supporting this initiative/program site through a funding mechanism beyond 1815 (e.g. DP18-1817, WISEWOMAN, state budget, other)? (select all that apply)

• No, our health department does not currently support this initiative/program through another funding mechanism

• We support this initiative/program through DP18-1817

• We support this initiative/program through state funding

• Other support, please specify all other funding sources to support this initiative/program: ____________________

• I don't know

Please specify and describe how else you work with this initiative/program?

______________________________________________________________

______________________________________________________________

______________________________________________________________

Why have you nominated this initiative/program for inclusion in the site-level rapid evaluation?

______________________________________________________________

______________________________________________________________

______________________________________________________________

What other information would you like to share about this initiative/program?

______________________________________________________________

______________________________________________________________

______________________________________________________________

(End of Page 13)

Thank you for completing the DSMES nominations for site-level rapid evaluation! 

(End of Page 14)