Form B—Applicant Description Page

Please note: Online form is for viewing purposes only. The online form CANNOT be submitted or saved.

Applicant Agency Name:

Please limit your response to this form to 5 pages.

1. Briefly provide an overview of population health in your state. When appropriate, please include demographics, priority public health and health care statistics and health disparities.

2. What division or component within your agency will have lead responsibility for implementing this project? Describe this division's experience implementing similar projects.

3. List each member of the project team, title, project role, education and experience implementing similar projects.

4. Describe the role of your Healthy People state coordinator in this project, if one has been designated.

5. What other divisions or components within your agency will be involved with this project? Describe their role. What other state, territory or tribal agencies or offices will be involved? Describe their role.

6. Describe your organization's past experience in working across sectors to improve the health of your population and the results of this work.

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This page last updated on: March 12, 2009

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