Application for Recognition

 

CDC welcomes organizations that offer a lifestyle program to prevent type 2 diabetes to apply for recognition by the Diabetes Prevention Recognition Program (DPRP), a component of the National Diabetes Prevention Program. The DPRP can help to assure consistent delivery of program elements across participating sites and provides evaluation, monitoring, and technical assistance for your program. Any organization with the capacity to deliver a lifestyle intervention meeting the DPRP standards may apply for recognition.

Applying for Recognition

Before you apply, you should read the CDC Diabetes Prevention Recognition Program: Standards and Operating Procedures [PDF–498KB]. This document spells out the criteria for delivering lifestyle interventions that meet the standards for full recognition by the DPRP. The standards document also contains a capacity assessment—a list of six questions to ask about your organization’s readiness to participate in the national program. You are strongly encouraged to conduct this assessment. Answering those questions will help you decide if your organization has the resources to start and maintain lifestyle classes that fit the requirements for full recognition.

To apply for recognition, complete the form on this page. After you submit the application form, you will receive a confirmation e-mail. This e-mail will include instructions for submitting an alternative curriculum, if applicable.

If you are using the recommended National Diabetes Prevention Program Curriculum, DPRP staff will notify you by e-mail of the outcome of your application within 15 working days. If you are using an alternative curriculum, DPRP staff will review your alternative curriculum along with your application. In this case, DPRP staff will notify you by e-mail of the outcome of your application within 30 working days of receiving your curriculum.

If you have any questions about your application or the DPRP, please call the Centers for Disease Control and Prevention’s help line, CDC-Info. Contact information for CDC-Info is given on the right-hand side of this Web page. Please ask the help desk staff for information about applying to the Diabetes Prevention Recognition Program. You may also send an e-mail to the help desk with the subject line “Diabetes Prevention Recognition Program Application.”

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Diabetes Prevention Recognition Program (DPRP) Application Form

Form Approved
OMB No. 0920-0909
Exp. Date 11/30/2014

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

GENERAL INFORMATION

1. Type of Application* Select Initial if your organization has not previously applied for recognition; Change if there has been a change in your organization’s contact information; Re-applying if your organization lost recognition and you are re-applying for recognition.

Initial   Change   Re-applying

2. Organization Code This code is assigned by the DPRP. If you are applying for the first time, choose Not Applicable. If you selected Change or Re-applying in the box above, enter your previously assigned organization code in this box. Not Applicable Enter Assigned Code

3. Organization Name* Upon approval of your application, this will be published in the DPRP registry and on the program’s Web site.

4. 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 Web site. Street Address:*

City:*

State:* - select - AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Puerto Rico Virgin Islands American Samoa Federated States of Micronesia Guam Northern Mariana Islands Marshall Islands Palau Other

Zip Code:* +4:

5. Organization Mailing Address Include if different from Organization Physical Address. DPRP staff will use this address to communicate by mail with your organization. Street Address:

City:

State: - select - AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Puerto Rico Virgin Islands American Samoa Federated States of Micronesia Guam Northern Mariana Islands Marshall Islands Palau Other

Zip Code: +4:

6. Organization Web Address or URL Optional. Upon approval of your application, if provided, this will be published in the DPRP registry and on the program’s website.

7. 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. Area Code - First Three - Last Four

CONTACT INFORMATION

8. Contact Person Name* The name of the individual who will be the applicant organization’s DPRP contact person. Salutation (e.g., Mr., Mrs., Dr., Ms., Miss, other [please specify]), last name, first name, middle initial, academic credentials (e.g., MD, RN, MPH, MPA, PhD, etc.). The contact person’s information will not be included in the registry.

Salutation: Mr. Mrs. Miss Dr. Other Last Name:* First Name:* Middle Initial: Academic Credentials:

9. Contact Person Title* The contact person’s title within your organization (e.g., Lifestyle Program Coordinator).

10. Contact Email Address* The contact person’s email address. DPRP staff will use this email address to communicate with your organization.

11. Contact Phone Number * The contact person’s phone number. DPRP staff will use this number to communicate with your organization. Area Code - First Three - Last Four

12. Contact Fax Number Optional. The contact person’s fax number. DPRP staff will use this number to communicate by fax with your organization. Area Code - First Three - Last Four

CURRICULUM INFORMATION (CHECK ONE)

13. Curriculum* If you select Other Curriculum, you must send your alternative curriculum to DPRP upon submission of your application. National Diabetes Prevention Program Curriculum Other Curriculum (must be submitted with application)

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 six months from the date of the initial lifestyle class for the purpose of program evaluation, continuing recognition and technical assistance. Name of Authorized Representative* Title of Authorized Representative* Organization Name*   Today's Date*

 

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