Application form is loading...
Skip directly to search Skip directly to A to Z list Skip directly to navigation Skip directly to page options Skip directly to site content
Sample Link

Apply for CDC Recognition

CDC - Application - Diabetes Prevention Recognition Program - National Diabetes Prevention Program - Diabetes DDT

Diabetes Prevention Recognition Program (DPRP) Application Form

Form Approved
OMB No. 0920-0909
Exp. Date 12/31/2020

Public reporting burden of this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0909).

*Indicates Required field

Hold controls for application form

    General Information

*
Previous OrgCode Assigned (Enter only if Re-Apply is selected)
*
Upon approval of your application, this will be published in the DPRP registry and on the program’s website.
3. Organization Physical Address (No P.O. Boxes)*
Upon approval of your application, this will be published in the DPRP registry and on the program’s website.
*
*
*
*
4. Organization Mailing Address
Include if different from Organization Physical Address. DPRP staff will use this address to communicate by mail with your organization.
Optional. Upon approval of your application, if provided, this will be published in the DPRP registry and on the program’s website.
Check URL Entry

NOTE: All web addresses must link directly to a location where participants can find information about the organization’s CDC-recognized lifestyle change program and enroll in the program. All web addresses published on the DPRP registry will be routinely reviewed for compliance.

6. Organization Phone Number*
This is the number that participants, payers, and others should call to obtain information about your program. Upon approval of your application, this will be published in the DPRP registry and on the program’s website.
- -
7. Organization Type *

    Program Coordinator

8. Program Coordinator Name*
The name of the individual who will serve as the applicant organization’s Program Coordinator and primary contact. Salutation (e.g. Mr., Ms., Mrs., Miss, Dr., other [please specify]), last name, first name, middle initial, academic credentials (e.g. MD, RN, MPH, MPA, PhD, etc. [please specify]). The Program Coordinator’s information will not be included in the registry.
*
*
9. Program Coordinator Contact Information*
The Program Coordinator’s contact information. DPRP staff will use this information to communicate with your organization.
*
*
Contact Phone Number *
- -
Contact Fax Number (optional)
- -

   Secondary Contact

   Data Preparer



    Program Delivery Information

14. Delivery Mode (check only one)*



*



write in target audience served such as American Indians/Alaskan Natives, patients, clients, etc.
16. Lifestyle Coach*
The primary training entity the applicant organization will use or has used to train their main Lifestyle Coaches.



*
NOTE: The full list of CDC Training entities are found here: https://www.cdc.gov/diabetes/prevention/lifestyle-program/staffing-training.html
17. Curriculum*
If you select Other Curriculum, you must submit your curriculum files.







*
  • Multiple files can be uploaded.
  • To upload more than one file follow these steps:
    1. Place your curriculum files into a single folder on your computer’s hard drive where you can easily find it.
    2. Click the browse button in the file upload box below.
    3. In the dialogue box that opens your file system, select the folder you created.
    4. Select all the files in the folder and click on Open.
    5. Confirm the correct number of files you selected in the upload window.
    6. Confirm the file names by moving your mouse over the upload window and checking the list that appears.
    7. Complete the rest of the form and submit your application.
  • Allowed file types: doc, docx, xls, xlsx, pdf.
  • Maximum length of file name: 200 characters.
  • Combined file size: 10MB (10,240 KB).
  • Maximum number of files: 20.

If you experience difficulty accessing the file upload control below, you may submit your files as email attachments. Please select the Accessibility Email Option below. After you complete your DPRP application and click to submit, please check your inbox for an automated email message with additional information and instructions for emailing your curriculum files.

*(at least one file is required if 'Upload Option' is selected)
  • If your curriculum files exceed the total size limit of 10 megabytes for online submission, please select 'Email Option' to indicate that you will be submitting your files as email attachments.
  • This email option should be used only when your curriculum is too large to submit online.
  • After you complete your DPRP application and click to submit, please check your inbox for an automated email message with additional information and instructions.

    Certification of Application

Electronic signature: By submitting this application, your organization asserts that it has thoroughly reviewed the CDC Diabetes Prevention Recognition Program: Standards and Operating Procedures and would like to participate in the CDC’s voluntary recognition program. Your organization agrees to comply with all of the recognition criteria contained in the standards document, including the transmission of data to CDC every 12 months from the date of the initial lifestyle class for the purpose of program evaluation, continuing recognition and technical assistance.
*
*
*
*

    Verification

 Top of Page

Get Email Updates

To receive email updates about this page, enter your email address:

What's this?Submit

Related Links

TOP