General Information
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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.
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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.
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.
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Contact Phone Number *
Contact Fax Number (optional)
Secondary Contact
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.
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