APPLICATION:
This application is available on the Community Pediatrics Training Initiative (CPTI) and AAP Obesity
websites: http://www.aap.org/commpeds/cpti/opportunities.htm and www.aap.org/obesity. Please
note that final submissions MUST be submitted by email.
All applications MUST be emailed to mbedient@aap.org by 2:00 p.m. Central on Friday,
November 18, 2011.
The 2011 Healthy Active Living Grants for AAP chapter/pediatric residency program pairs is funded by
the MetLife Foundation.
CONTACT INFORMATION:
AAP chapter:
Pediatric residency program:
Primary contact at AAP chapter:
Name and credentials:
Title:
Address:
City, State, Zip:
Phone:
Fax:
Email:
Secondary contact at AAP chapter:
Name and credentials:
Title:
Address:
City, State, Zip:
Phone:
Fax:
Email:
Primary contact at pediatric residency program:
Name and credentials:
Title:
Address:
City, State, Zip:
Phone:
Fax:
Email:
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Secondary contact at pediatric residency program:
Name and credentials:
Title:
Address:
City, State, Zip:
Phone:
Fax:
Email:
DEMOGRAPHICS (NOT SELECTION CRITERIA):
A. Do children with any of these types of health care coverage comprise 50% or more of the
project's target population? Check no more than 2 boxes.
Indian Health Service
Medicaid/SCHIP recipients
Private Insurance
Uninsured children
Other (specify
)
B. What is the race/ethnicity of the project's primary target population? Check all that apply.
Asian/Pacific Islander
Black
Hispanic
Native American
White, non-Hispanic
Other (specify
)
C. Please characterize the target community for the project. Check all that apply.
Urban, inner city
Urban, not inner city
Suburban
Rural
Other (specify
)
PROJECT TITLE AND ABSTRACT:
Title of proposed initiative:
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Proposal summary/abstract addressing the overall goals of the initiative (250 word limit):
COLLABORATION AND INTEGRATION:
1) Describe the role of both the AAP chapter and the pediatric residency program in this
proposal (150 word limit).
2) What kind of team has been developed to implement and ensure sustainability of the
proposed initiative? Describe the team members and their roles (150 word limit).
3) Describe how the proposed initiative fits into the chapter’s activities and strategic plan and
how the proposed initiative will be incorporated into community pediatrics residency training
activities (150 word limit).
COMMUNITY OVERVIEW:
4) Describe the community being served (150 word limit).
5) Identify community collaborative partners for this program (e.g., grassroots associations,
parents, faith-based groups, local businesses, local public health service agencies, child care
facilities, hospitals) (150 word limit).
6) What are the barriers in this community to achieving healthy active living, particularly
around physical activity? (e.g., geographic, cultural, socioeconomic, communication) (150
word limit).
7) Identify the primary setting of your project (Priority will be given to projects that
demonstrate a coordinated multipronged approach targeting multiple intervention levels)
(150 word limit).
TARGET POPULATION:
8) Describe the target population for this initiative (including the number of children to be
impacted and demographic data) (150 word limit).
9) How will the proposed initiative support and promote healthier active living especially for
children birth to five (150 word limit):
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PROJECT PLAN:
10) Describe the project plan and related goals. Provide a timeline for accomplishing these
objectives (not to exceed the 18 month funding period) (250 word limit).
11) Describe how you will measure the achievement of your goals and objectives. (250 word
limit).
11) Identify the long-range goals for this project, plans for sustainability, and replication in
other communities beyond the grant period (including sources of potential future funding)
(250 word limit).
12) Budget detail and brief justification (not to exceed $25,000).
Activity
Description/Formula
TOTAL Amount Requested
$ Amount
$
Additional notes/justification:
SIGNATURES AND LETTERS OF SUPPORT:
With assistance from my organization/institution, I am willing to participate in the Healthy
Active Living Grant per the roles and responsibilities outlined on the request for applications
document.
Reviewed by Chapter President and letter of support included (required)
Reviewed by Residency Program Director and letter of support included (required) p.m. Eastern on
January 15, 2010.
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