Healthy People 2030 Applicant Information

OMB No. 0990-0281 — Expires 10/31/2024

Healthy People 2030 Applicant Information

Point of Contact Information

1. Name * *This question is required.

2. Email * *This question is required. This question requires a valid email address.

3. Phone Number (for example, 555-555-5555)* *This question is required.

4. Extension Number

5. Alternate Point of Contact Name

6. Alternate Email This question requires a valid email address.

7. Alternate Phone Number (for example, 555-555-5555)

8. Alternate Extension Number

Organization Information

9. Name * *This question is required.

10. Address * *This question is required.

11. Website URL * *This question is required.

12. Year of Organization’s Establishment * *This question is required. This question requires a valid number format.

13. Type of Organization (Select all that apply) * *This question is required.

14. Please list the type of your organization here * *This question is required.

14. Please indicate whether your organization works at (Select all that apply) * *This question is required.

15. Please describe which level your organization works at * *This question is required.

15. Provide a brief description of your organization below, identifying the organization’s, mission, vision, and purpose (500 words or less) * *This question is required.

16. Please describe the populations your organization serves (for example, communities of color, people living in rural areas, people with disabilities, seniors, LGBTQ+ youth, military families and military veterans) (500 words or less)* *This question is required.

17. Please estimate the reach (for example, number of followers or subscribers) of each of your organization's communication vehicles * *This question is required.

Space Cell	Social Media Handle (if applicable)	Estimated reach
Twitter	Twitter: Social Media Handle (if applicable)	Twitter: Estimated reach
Facebook	Facebook: Social Media Handle (if applicable)	Facebook: Estimated reach
YouTube	YouTube: Social Media Handle (if applicable)	YouTube: Estimated reach
Newsletter	Newsletter: Social Media Handle (if applicable)	Newsletter: Estimated reach
Instagram	Instagram: Social Media Handle (if applicable)	Instagram: Estimated reach
Enter another option	Other: Social Media Handle (if applicable)	Other: Estimated reach
Enter another option	Other: Social Media Handle (if applicable)	Other: Estimated reach
Enter another option	Other: Social Media Handle (if applicable)	Other: Estimated reach
Enter another option	Other: Social Media Handle (if applicable)	Other: Estimated reach

18. Please describe the types of organizations you partner with (for example, schools, faith-based organizations, community health centers) and their role in helping achieve your organization's mission (500 words or less)* *This question is required.

19. Please provide a description and an estimate of the number of people served by (or members of) your organization (500 words or less)* *This question is required.

20. Please indicate whether your organization is involved in cross-sector activities with the following sectors (Select all that apply) * *This question is required.

21. Please list sectors here (500 words or less)* *This question is required.

Organization’s support of Healthy People 2030

21. Please provide a brief statement on how your organization works to address disease prevention and health promotion. Please provide at least 1 specific example of your work in these areas (500 words or less)* *This question is required.

22. Please provide a brief statement on how your organization works to address social determinants of health, health disparities, or health literacy and to achieve health equity or well-being as outlined in the Healthy People 2030 Framework. Please provide at least 1 specific example of your work in these areas (500 words or less)* *This question is required.

23. Healthy People 2030 Champions are asked to commit to supporting the overarching goals and objectives of Healthy People 2030. Please identify at least 2 Healthy People 2030 topics or objectives your organization is committed to addressing during the course of the decade (500 words or less)* *This question is required.

* Required

For more information about the Healthy People 2030 Champion Program, check out the Federal Register Notice.