Preconception Health in Minnesota Grant Program
Request for Proposals
Application Materials
July 1, 2014 – June 30, 2016
Issue date:
January 27, 2014
Updated March 11, 2014
Application Deadline Extended to April 4, 2014
Erica Fishman, MSW, MPH, LISW
Minnesota Department of Health
Division of Community and Family Health
Children and Youth with Special Health Needs Section
P.O. Box 64882
St. Paul, MN 55164-0882
651-201-3650
http://www.health.state.mn.us/birthdefects
1
Birth Defects Monitoring and Analysis Program
Minnesota Department of Health
Community and Family Health Division
Children with Special Health Needs Section
P.O. Box 64882
St. Paul, MN 55164-0882
Street Address
85 E. 7th Place
St. Paul, MN 55101
(651) 201-5141 phone
E-mail: erica.fishman@state.mn.us
2
MEMORANDUM
DATE:
January 27, 2014
TO:
Agencies Intending to Apply for Preconception Health in Minnesota Grant
Program
FROM:
Erica Fishman, MSW, MPH, LISW
Birth Defects Prevention and Education Specialist
SUBJECT:
Preconception Health in Minnesota Application Materials for
July 1, 2014 – June 30, 2016
This memorandum is to acknowledge your interest in the Preconception Health in Minnesota
Grant program and transmit application materials and information relative to the grant review
process. Applications are to be submitted for July 1, 2014 through June 30, 2016. The possibility
of a two year extension will be contingent upon satisfactory performance and continuation of
funding.
To assure that applications are submitted in accordance with all requirements:



Use the project application checklist (page 16), the instructions, the application and
forms, and the criteria for grant review score sheet (see Appendix A) as guides during the
application process. The application instructions are written to correspond to the order of
review questions on the score sheet.
Check for required signatures.
Number all pages consecutively.
The deadline for submission of proposals is Friday, March 14, 2014 extended to Friday,
April 4, 2014. To meet the deadline, an unbound original and five unbound copies of the
completed application must:
1) Be hand delivered to the address below before 4:00 p.m. Friday, March 14, 2014
extended to Friday, April 4, 2014; or
2) Have a legible postmark from the United States Postal Service or private carrier dated on
or before 4:00 p.m. Friday, March 14, 2014 extended to Friday, April 4, 2014.
Postmarks from a private, in-office metering machine are not acceptable.
LATE APPLICATIONS WILL NOT BE ACCEPTED.
Applications will be reviewed and scored as submitted.
We trust this information will assist you in preparing and submitting a complete grant
application. If you have questions during the application process, you are encouraged to contact
Erica Fishman at Erica.Fishman@state.mn.us or (651) 201-5141.
The application can be downloaded from www.health.state.mn.us/birthdefects.
3
Preconception Health in Minnesota Grant Program
Table of Contents
Preconception Health in Minnesota Grant Program ............................1
Table of Contents ...............................................................................4
APPLICATION MATERIALS ................................................................................... 6
I.
INTRODUCTION ............................................................................................................................. 6
II.
MDH ADMINISTRATIVE/TECHNICAL PROGRAM SUPPORT ........................................................... 6
III. APPLICATION SUBMISSION PROCESS............................................................................................ 7
IV. GRANT APPLICATION REVIEW AND AWARD PROCESS ................................................................. 7
V.
PROGRAM SUMMARY ................................................................................................................... 8
VI. OVERVIEW/REQUIREMENTS OF THE PRECONCEPTION HEALTH IN MN GRANT PROGRAM ...... 11
VII. INSTRUCTIONS, APPLICATION AND FORMS ................................................................................ 14
Form 1 – Project Application Checklist .......................................................................................... 16
Form 2 – Project Abstract .............................................................................................................. 17
Form 3 – Application Face Sheet ................................................................................................... 18
Form 4 – Due Diligence Review Form ............................................................................................ 20
Form 5 – MDH Evidence of Compliance with Worker’s Compensation ........................................ 25
Form 6 – Assurances and Agreements .......................................................................................... 26
Form 7 – Governing Board Resolution ........................................................................................... 28
VIII. PROJECT NARRATIVE, WORK PLAN AND BUDGET ................................................................. 29
Form 8 – Organizational Capacity .................................................................................................. 29
Form 9 – Needs Assessment and Target Population ..................................................................... 32
Form 10 – Work Plan ..................................................................................................................... 35
Form 11 – Budget Justification ...................................................................................................... 43
Form 12 – Budget Summary .......................................................................................................... 49
Form 13 – Administrative - Indirect Cost Allocation for CYSHN Section Grants ............................ 51
Form 14 – Administrative – Indirect/Cost Allocation Worksheet.................................................. 52
References ........................................................................................................ 53
Appendices ....................................................................................................... 54
Appendix A – Preconception Health in Minnesota Criteria for Grant Review Score Sheet .......... 55
4
Appendix B – Preconception Health Focus Areas .......................................................................... 61
Appendix C – Preconception Health Risk Assessment & Focus Area Interventions ...................... 62
Appendix D – Resources and References ...................................................................................... 68
Appendix E – PRAMS Research ...................................................................................................... 75
5
APPLICATION MATERIALS
I.
INTRODUCTION
This document provides the forms and guidance you will need to apply for the
Preconception Health in Minnesota Grant Program. It is suggested that you review this
document completely, including the appendices before writing the application. The
application includes sections that cover information about what organizations are eligible
to apply, the general proposal, instructions for the project work plan and budget, and
grant review criteria. Appendices A-E include information about criteria for grant review
and scoring, possible preconception health focus areas, a summary of relevant Minnesota
PRAMS research data and resources for additional information about preconception
health. This request for proposals and additional resources can be found at:
www.health.state.mn.us/birthdefects
II.
MDH ADMINISTRATIVE/TECHNICAL PROGRAM SUPPORT
MDH will provide limited consultation and guidance regarding the grant application
process. Two identical webinars/conference calls will be held on Wednesday, February 5,
2014 at 1:00 p.m. and on Thursday, February 6, 2014 at 10:30 a.m.
An additional webinar will be held on Monday, March 17 at 10:00 a.m. to orient
applicants to the program requirements, application instructions, and respond to questions
in this regard. MDH Preconception Health Staff will be available to respond to questions
before and after the webinars/conference calls. Staff will not be able to help with the
actual writing of applications or critiques of drafts. To register for the
To register for ONE of the FEBRUARY webinars/conference calls, please visit the
MDH Birth Defects website http://www.health.state.mn.us/birthdefects, click on
Preconception Health Grant RFP, and click on the registration link. Please submit your
questions about the Request for Proposal via email to birth defects email box by 4:30
p.m. on February 3, 2014, for inclusion in the webinars. Emailed questions and a
summary of the webinars will be compiled as a Frequently Asked Questions (FAQ)
document by 4:30 p.m. Monday February 10, 2014. Questions received after the webinars
will be posted to the FAQ document which will be updated every Friday until March 7,
2014.
To register for the March 17, 2014 webinar, send an email to
HEALTH.birthdefects@state.mn.us.
Please email questions to HEALTH.birthdefects@state.mn.us. The FAQ document will
be posted on the MDH Birth Defects website http://www.health.state.mn.us/birthdefects
Preconception Health Grant RFP web page. The FAQ document will be updated every
Friday until March 28, 2014.
6
APPLICATION SUBMISSION PROCESS
A. Applications must contain Forms 1 through 14. All copies of the application should
be unbound. For the convenience of the reviewers, the pages should be numbered
consecutively, the applicant agency name included on each page, and the font size
should be no less than 12 points. Narrative pages should be double-spaced with one
inch margins.
Letters of support from collaborative partners are not required and will not be
passed on to the reviewers.
Supplemental tapes, videos, brochures, pamphlets, annual reports, etc. are not
required, will not be passed on to the reviewers and will be discarded.
B. Mail the unbound original and five (5) unbound copies of the completed
application to:
Minnesota Department of Health
Division of Community and Family Health
Attn: Erica Fishman
P.O. Box 64882
St. Paul, MN 55164-0882
OR
C. Deliver to 85 East Seventh Place, Suite 220, St. Paul, MN 55101
a. Hand delivered proposals must be dropped off at the 2nd floor MDH reception
desk in the Golden Rule Building – Suite 220 by 4:00 p.m.
b. FAXED OR E-MAILED APPLICATIONS WILL NOT BE ACCEPTED
c. LATE APPLICATIONS WILL NOT BE ACCEPTED
Applications must be received or have a legible postmark from the United States Postal
Service or a legible drop off time from MDH or a private carrier with a date, no later
than, Friday March 14, 2014 extended to Friday, April 4, 2014, 4:00 p.m.
III.
GRANT APPLICATION REVIEW AND AWARD PROCESS
A. Competitive Grant Process
All applications for the Preconception Health in Minnesota Grant Program which meet
the application deadline will be reviewed competitively relative to the Criteria for Grant
Review Score Sheet (Appendix A). Applications not received or mailed by the Friday,
March 14, 2014 extended to Friday, April 4, 2014 deadline will not be reviewed.
Reviewers will determine which application proposals best meet the criteria and will best
accomplish the purpose for which the program was established. Grant reviewers may
7
include staff from MDH and other state agencies with grant management expertise; and
individuals from other organizations that represent a broad range of professionals with
experience in program planning and project management, knowledge of women’s health
promotion or birth defects prevention, and experience with grant writing and reviewing
grants. Reviewers will be required to identify any conflicts of interest and will not review
a proposal if they have a direct relationship with the applicant.
Reviewer scores will be initially used to rank statewide all applications. In addition to
reviewer scores, the issues of geographic distribution, priority populations and reviewers
funding recommendations will be considered in the final grant award decision process.
Applications which fail to meet program requirements will not be approved. Applicants
with current Preconception Health grant awards may have past performance taken into
consideration. Community and Family Health Division staff will recommend to the
Commissioner of Health applications for funding. The decisions on grant awards made
by the Commissioner will be final.
B. Award Letter and Execution of Contract
It is anticipated that the notification letters will be sent to all applicants on approximately
May 9, 2014. The revised date is approximately May 19, 2014.
Thereafter, a grant contract will be executed with the applicant agencies awarded the
funds. The effective date of the contract will be July 1, 2014 or the date, upon which all
signatures to the agreement are obtained, whichever is later. The Grant awards will be
made for the period July 1, 2014 through June 30, 2016 with the possibility to extend
awards for another two years.
The contractor will be legally responsible for assuring the implementation of the work
plan, compliance with all state and federal requirements, including worker’s
compensation, nondiscrimination, data privacy, budget compliance, and reporting
requirements.
IV.
PROGRAM SUMMARY
The Preconception Health in Minnesota Grant Program funds will be made available to support
communities through the grants as follows:
Eligibility for Grant Funds
Total Funds Available
Eligible applicants include: Community Health Boards, local public
health agencies, tribal governments, clinics, hospitals and nonprofit community organizations serving clients in Minnesota.
The total funding for the Preconception Health in Minnesota Grant
Program is approximately $600,000 for two years. MDH expects to
award 4-6 grants, each with awards ranging between $30,000 and
$65,000 for each year of the grant cycle. Applicant budgets cannot
exceed $65,000 per year and may not be shorter or longer than
grant period. There is no requirement for matching funds or in-kind
8
Grant Cycle
Grant Purpose
contributions. The amount of money available is subject to change.
Two years beginning July 1, 2014 and ending June 30, 2016. The
possibility of a two year extension will be contingent upon
satisfactory performance and continuation of funding.
To improve preconception health and care for non-pregnant,
reproductive age women and their partners in Minnesota, through
support of evidence-based preconception health practices and
programs that prevent and/or reduce the risk for birth defects. A
priority audience for this grant is women experiencing racial and
ethnic disparities in health status.
Funded projects under this program will work to improve women’s
health prior to a pregnancy. All projects must incorporate a routine
risk assessment of preconception health needs for non-pregnant
women of reproductive age and address at least one of the
following four preconception birth defects risk factor focus areas
of: Reproductive Health, Substance Use and Exposure, Nutrition
and Weight, and Chronic Disease (see Appendix B for specific
topic areas allowable in each of the four focus areas and
Appendices C and D for examples of interventions).
Application Requirements



Narrative portions of the application must be in 12-point
font with one-inch margins and be double spaced
All pages should be numbered consecutively and should
contain the applicant agency name
Submitted proposals must include completed required forms
provided in this application packet and listed below
One signed unbound original and five copies should be
submitted
Applications must meet the time and date deadline
requirements. Late applications will not be reviewed
Applications must be complete and signed where noted
Faxed or emailed applications will not be accepted











Project Application Checklist (Form 1)
Project Abstract (Form 2)
Face Sheet (signature required) (Form 3)
Due Diligence Review Form (Form 4)
Evidence of Compliance (Form 5)
Assurances and Agreements (Form 6
Governing Board and Resolution (Form 7)
Organizational Capacity (Form 8)
Needs Assessment and Target Population (Form 9)
Work Plan (Form 10)
Budget Justification (Form 11 )




Application Instructions
and Application Forms
9



Application Deadline
Applications Sent
Budget Summary Sheet (Form 12)
Administrative- Indirect/Cost Allocation (Form 13)
Administrative-Indirect/Cost Allocation Worksheet (Form
14 )
All applications must be received by MDH or postmarked no later
than 4:00 p.m. on Friday March 14, 2014 extended to Friday,
April 4, 2014. Please consider this deadline when mailing
applications. Faxed or e-mailed applications will not be
accepted. Late applications will not be considered for review.
Delivery Address:
Minnesota Department of Health
Division of Community and Family Health
ATTN: Erica Fishman, MSW, MPH, LISW
Birth Defects Prevention and Education Specialist
85 East Seventh Place, Suite 220
St. Paul, MN 55101
Mailing Address:
Minnesota Department of Health
Division of Community and Family Health
ATTN: Erica Fishman, MSW, MPH, LISW
Birth Defects Prevention and Education Specialist
P.O. Box 64882
St. Paul, MN 55164-0882
Beginning Grant
Agreement Date
July 1, 2014 or date upon which all signatures to the agreement are
obtained, whichever is later.
10
V.
OVERVIEW/REQUIREMENTS OF THE PRECONCEPTION HEALTH IN MN
GRANT PROGRAM
Program Goal and Components
The goal of the Minnesota Department of Health (MDH) in making these grants is to
improve preconception health for non-pregnant, reproductive age women and their partners
in Minnesota through support of evidence-based preconception health practices and programs
that prevent and/or reduce the risk for birth defects. These projects will assist MDH in
discovering promising approaches utilizing evidence-based practices and programs for
delivering preconception care and to learn from each grantee the effectiveness of individual
and community based interventions and potential applicability to other settings and
populations in Minnesota. A brief description of a birth defect follows.
A birth defect is a problem that happens while a baby is developing in
the mother's body. Most birth defects happen during the first 3 months of
pregnancy. One out of every 33 babies in the United States is born with a
birth defect.
A birth defect may affect how the body looks, works or both. Some birth
defects like cleft lip or neural tube defects are structural problems that
can be easy to see. To find others, like heart defects, doctors use special
tests. Birth defects can vary from mild to severe. Some result from
exposures to medicines or chemicals. For example, alcohol use during
pregnancy can cause fetal alcohol syndrome. Infections during
pregnancy can also result in birth defects. For most birth defects, the
cause is unknown.
Most birth defects are thought to arise from a complex mix of factors.
These factors include our genes, our behaviors, and things in the
environment. For some birth defects, we know the cause. But for most,
we don’t. Some birth defects can be prevented. Taking folic acid can
help prevent some birth defects. Some medicines can cause serious birth
defects.
Babies with birth defects may need surgery or other medical treatments.
Today, doctors can detect many birth defects prenatally. This enables
them to treat or even correct some problems before the baby is born.
Adapted from: Medline Plus; U.S. National Library of Medicine,
National Institutes of Health website
http://www.nlm.nih.gov/medlineplus/birthdefects.html Accessed
11/15/13
Additional information about prevention of birth defects can be found on
the CDC’s website at:
http://www.cdc.gov/ncbddd/birthdefects/prevention.html Accessed
11/30/13
11
Despite some improvements in pregnancy-related health statistics over recent years, risk factors
for poor pregnancy outcomes remain of great concern. While prenatal care starting at 11-12
weeks of pregnancy is often too late to address many of the risk factors for poor pregnancy
outcomes, including birth defects, preconception health and care holds promise. Preconception
care encompasses a range of health promotion, risk identification, preventive and curative
measures. Some of the known risk factors for birth defects fall into preconception health
categories (see appendix B and C). Positive preventive steps women can take in these categories
include:




reproductive health
o reproductive life planning, planned pregnancies - ensuring adequate
pregnancy intervals
substance use and exposure
o avoidance of alcohol, tobacco and illegal or “street” drugs; avoidance of
teratogenic drugs and other medication affecting birth outcomes; and
avoidance of environmental exposures that can have teratogenic effects
such as certain chemicals
nutrition and weight
o adequate folate intake or folic acid supplementation prior to pregnancy,
adequate nutrition before pregnancy, achieving a healthy prepregnancy
BMI –reducing obesity and overweight
chronic disease
o ensuring women with diabetes are in good glycemic control before
pregnancy, management of hypertension, management of teratogenic
medications relate d to chronic disease including diabetes, and
hypertension.
One of the objectives of Healthy People (HP) 2020 is to “increase the proportion of women
delivering a live birth who received preconception care services and practiced key recommended
preconception health behaviors.”1 According to the Centers for Disease Control and Prevention
(CDC), preconception care is “a set of interventions that identify and modify biomedical,
behavioral, and social risks to a woman’s health and future pregnancies. It includes both
prevention and management, emphasizing health issues that require action before conception or
very early in pregnancy for maximal impact.”2
The table below features the HP 2020 indicators related to preconception care services and
behaviors found in the Maternal, Infant, and Child Health Objective 16 (MICH-16). It also
includes Minnesota-specific baselines using data from the MN-Pregnancy Risk Assessment and
Monitoring System (PRAMS).
1
2
(U.S. Department of Health and Human Services, 2011)
(NCBDDD, CDC, 2006)
12
HP 2020: Select MICH-16 Indicators
MICH 16.1(Developmental): Discussed
preconception health with a health care
worker prior to pregnancy
MICH 16.2: Took multivitamins/folic
acid every day in the month prior to
pregnancy
MICH 16.3: Did not smoke in the three
months prior to pregnancy
MICH 16.4: Did not drink alcohol in the
three months prior to pregnancy
MICH 16.5: Had a healthy weight (BMI
of 18.5-24.9) prior to pregnancy
National
Baseline %,
2007
Not available
National
Target %
Not
available
*MN
**MN %
%200720092008
2010
Not
35.1
available
30.1
33.1
34.2
34.8
77.6
85.4
76.6
74
51.3
56.4
35.9
32.8
48.5
53.4
53.0
53.1
* According to 2007-2008 data from the MN-Pregnancy Risk Assessment Monitoring System (PRAMS) 3
**According to 2009-20010 data from the MN-Pregnancy Risk Assessment Monitoring System (PRAMS)
Although Minnesota meets some of these targets for HP 2020, there is still room for
improvement. Additionally, the percentages are especially low for certain subgroups of the
population as noted in Appendix E (2007-2008 data).
Project Requirements
Funded projects under this grant will work to improve women’s health prior to a pregnancy. All
projects must incorporate into their activities a routine risk assessment of preconception health
needs for non-pregnant women of reproductive age. Counseling must be provided for the risks
identified and referrals provided as appropriate.
The projects must also address at least one of the following four preconception birth defects risk
factor focus areas of: Reproductive Health, Substance Use and Exposure, Nutrition and Weight,
and Chronic Diseases. Appendix B indicates the categories under each of the focus areas that are
allowable under this grant.
Interventions must be evidence-based practices or programs. For a definition of “evidence-based
interventions” please see the work plan instructions. Examples of evidence-based practices and
programs that may be included as part of program activities can be found in appendix C and
additional resources for acceptable programs or tools can be found in appendix D. Applicants
may also propose interventions not included in this list, with adequate explanation of the
evidence that currently exists to support those interventions.
3
(Barber, Harvey, & Punyko, 2011)
13
Evaluation Requirement
A minimum of 5% of the total direct funds must be set aside in the budget for evaluation
activities. Applicants must identify in their work plan possible process and outcome evaluation
measures. In addition, if the applicant is awarded funds, they will be required to work with the
MDH Children and Youth with Special Health Needs and Maternal and Child Health staff to
further develop and finalize an evaluation plan that will be approved by the state within three
months of having a fully executed contract. The plan will include standardized procedures to
monitor and assess accomplishments relative to the approved objectives/work plan and account
for how the 5% of total direct funds will be spent. Grantees will also be required to participate in
a state level evaluation that includes reporting on cross-site measures. Grantees will be required
to provide quarterly narrative progress reports and a final summary report at the end of the grant
period. Reporting forms for the quarterly narrative progress report will be provided by the state.
Financial reports with invoices for grant expenditure reimbursements are due with the narrative
progress reports. Reimbursements will not be processed until the narrative report is received and
approved.
VI.
INSTRUCTIONS, APPLICATION AND FORMS
The following instructions should be carefully followed to prepare a complete grant application.
Agencies should format their application consistent with the order of items presented in these
instructions. The order of application forms corresponds to the order of questions asked on the
score sheet which grant reviewers will use to evaluate the grant applications.
A. Project Application Checklist (Form 1)
Insert page numbers for all forms in right column (forms 1-14).
B. Project Abstract
Complete the information that applies to your application. In 350 words or less, provide
a summary of your proposed projects (Form 2).
C. Minnesota Department of Health Face Sheet (Form 3)
See instructions for completing Face Sheet.
Note: The distinction between applicant agency and operating agency applies primarily
to multi-county Community Health Boards and their component counties. Individual
counties may operate a project (operating agency), but the agency which submits the
application and enters into the contract with the state is the Community Health Board
(applicant agency).
D. Due Diligence Review Form (Form 4)
This form must be completed by all applicants that are not government entities such as
cities, counties, community health boards and tribes. No applicants will be excluded in
receiving funding based solely on the answers to these questions. (Note: required
documentation requested, i.e. 990, etc.).
14
E. Evidence of Compliance with Worker’s Compensation Requirements (Form 5)
See Evidence of Compliance instructions printed on form. Complete all applicable items.
Attach a certificate of insurance if needed.
F. Assurances and Agreements (Form 6)
By signing and submitting the Assurances and Agreements pages, the applicant agency is
agreeing to comply with applicable federal and state requirements. These items need not
be addressed in any other manner.
The form should be signed by the person authorized to legally bind the applicant agency
to contractual agreements.
G. Governing Board Resolution (Form 7)
The form should be signed by the person authorized to legally bind the applicant agency
to contractual agreements. Another document can be submitted if it contains all the
required information and is labeled “Form 7”.
H. Organizational Capacity (Form 8)
Complete a narrative description of the organization proposing the project.
I. Needs Assessment & Target Population (Form 9)
Complete a narrative description of the community the project proposes to serve and
describe the target population.
J. Work Plan (Form 10)
Complete the work plan form describing steps, activities, tasks to achieve objectives.
K. Budget Justification (Form 11)
For each grant year, complete the budget form describing budget items and their
rationale. You will need to submit one form for the year July 1, 2014-June 30, 2015 and
one form for year July 1, 2015-June 30, 2016.
L. Budget Summary Form (Form 12)
Complete one form for the two year budget period.
M. Administrative-Indirect Cost Allocation (Form 13)
Please check one of the four options.
N. Administrative-Indirect Cost Allocation Worksheet (Form 14)
Complete the allocation worksheet form applicable to your program.
15
Form 1 – Project Application Checklist
Blank
Page No.
Project Application Checklist (Form 1)
Project Abstract (Form 2)
Minnesota Department of Health Face Sheet (Form 3)
Due Diligence Review Form (Form 4)
Evidence of Compliance with Worker's Compensation Requirements (Form 5)
Assurances and Agreements (Form 6)
Governing Board and Resolution (Form 7)
Organizational Capacity (Form 8)
Needs Assessment and Target Populations (Form 9)
Work Plan (Form 10)
Budget Justification (Form 11) – submit one form for each year
Budget Summary– two year budget (Form 12)
Administrative – Indirect Cost Allocation (Form 13)
Administrative - Indirect Cost Allocation Worksheet (Form 14)
An unbound original and five (5) unbound copies by Friday March 14, 2014
extended to Friday, April 4, 2014, 4:00 p.m.
Mail (USPS) to:
Minnesota Department of Health
Children and Youth with Special Health Needs Section
Attn: Erica Fishman
P.O. Box 64882
St. Paul, MN 55164-0882
Deliver to in person, couriers or surface deliveries such as FedEx or UPS:
85 East Seventh Place, Suite 200, St. Paul, MN 55101
16
Blank Cell
Form 2 – Project Abstract
Name of Agency: ________________________________________________________
Name of Project: _________________________________________________________
Agency: LPH agency___ Clinic___ Tribal Government___ Non-profit___
Other (please describe) ___________
Geographic area to be served: _________________________
Amount of fund requested:
July 1, 2014 –June 30, 2015_________________________
July 1, 2015 – June 30, 2016_________________
Project focus area(s): check all that apply
Reproductive Health: Reproductive Life Plans___ Planned Pregnancies___
Substance Use and Exposure: Alcohol___ Tobacco___ Illicit or “street” drugs___
Teratogenic Medication Management__ Environmental Exposures___
Nutrition and Weight: Folic Acid/Folate___ Obesity/Overweight__
Chronic Disease: Diabetes___Hypertension___
Project Abstract: Using the space below, please summarize the project in 350 words or less.
17
Form 3 – Application Face Sheet
Instructions
Please complete all items on the Application Face Sheet.
1. Applicant Agency
Legal name of the agency authorized to enter into a grant contract with the Minnesota
Department of Health.
2. Applicant Agency’s Minnesota and Federal Tax I.D. Number
3. Non-Profit Status – 501 (c) 3 Copy Attachment
Check appropriate answer. Agencies other than a governmental unit are required to file a
501 (c) 3 form with the application as evidence the agency is a non-profit institution,
corporation, or organization.
4. Requested Funding for the Total Grant Period
Amount the applicant agency is requesting in grant funding for the grant period (7/1/14 6/30/16)
5. Director of the Applicant Agency
Person responsible for directing the applicant agency.
6. Fiscal Management Officer of Applicant Agency
The chief fiscal officer for applicant agency who would have primary responsibility for
grant agreement and grant funds expenditure and reporting.
7. Operating Agency
Complete only if other than the applicant agency listed in number 1 above.
8. Contact Person for Operating Agency
Person who may be contacted concerning questions about implementation of this
proposed program. Complete only if different from the individual listed in number 5.
9. Contact Person for Further Information
Person who may be contacted for detailed information concerning the application, or the
proposed program.
10. Signature of Authorized Agent of Applicant Agency for Grant Agreement
Provide original signature of the Authorized Agent of the applicant agency and the date
signed.
18
Form 3 – Application Face Sheet
Minnesota Department of Health
Preconception Health in Minnesota Grant Program
1. Legal name and address of the applicant agency with which grant agreement would be executed:
2. Minnesota Tax I.D. Number: ______________
3. Non-Profit Status – Copy of 501 (c) 3 attached:
Federal Tax I.D. Number______________
Yes________________________Not Applicable
4. Requested funding for the total grant period (7/1/14 -6/30/16): $_________________________
5. Director of applicant agency
Name, Title, and Address:
Email Address:
Telephone Number: ()
Fax Number: ()
6. Fiscal management officer of applicant agency
Name, Title, and Address:
Email Address:
Telephone Number: ()
Fax Number: ()
7. Operating agency (if different from number 1 above):
Name, Title, and Address:
Email Address:
Telephone Number: ()
Fax Number: ()
8. Contact person for operating agency (if different from number 5 above):
Name, Title, and Address:
Email Address:
Telephone Number: ()
Fax Number: ()
9. Contact person for further information on grant application:
Name, Title, and Address:
Email Address:
Telephone Number: ()
Fax Number: ()
10. Certification
I certify that the information contained herein is true and accurate to the best of my knowledge and that I
submit this application on behalf of the applicant agency.
____________________________________
___________________________
Signature of Authorized Agent
Title
For Grant Agreement
19
____________
Date
Form 4 – Due Diligence Review Form
** Instructions **
This form should be completed by your organization’s administrative staff, for example,
Finance Manager, Accountant or Executive Director.
The Due Diligence Review Form has two purposes:
 It is a standard form MDH uses to determine the accounting system and financial
capability of all grant applicants that will be receiving at least $50,000. It will help us
assess whether your organization is likely to need additional technical assistance to
properly administer our grant funds.
It helps us comply with Minnesota’s Office of Grants Management Policy 08-06,
which requires a financial review of the applicant’s financial status before we award
a grant of at least $25,000 to any entity that is not a government agency or a tribal
government.

If you will be using a fiscal agent, answer these questions for the fiscal agent. Otherwise,
answer them for your organization.
The boxes will expand as you type. Use 12-point font. There is no page limit for the Due
Diligence Review Form.
I.
Applicant Information
Enter the indicated information.
II.
Accounting System
Enter the indicated information about the accounting system of the lead organization
or the fiscal agent.
III.
Fund Control
Enter the indicated information about the lead organization or the fiscal agent.
IV.
Financial Statements
Enter the indicated information about the lead organization or the fiscal agent.
V.
Type of Organization
Indicate whether the lead organization or the fiscal agent is a government agency,
tribal government, or non-governmental organization by typing an X.
20
VI.
Type of Documentation
Government agencies and tribal governments do not need to complete this section or
include any documentation in their applications.
The type of documentation that we are required to review for other types of
organizations depends on the size of the applicant’s budget:



Applicants that are new or have an annual income under $25,000 should submit their
most recent board-reviewed financial statements.
Applicants that have an annual income under $750,000 should submit their most
recent IRS Form 990.
Applicants that have an annual income over $750,000 should submit their most recent
certified financial audit.
Indicate which type of documentation applies to the organization by typing an X. Include
the required documentation in your application.
VII.
Describe Existing Debt
Provide information on any new debt that has been occurred in the last six months,
such as a new mortgage, other loan, or a line of credit. This information should reflect
the information that is not reflected in the financial documents you are submitting.
In addition, provide information on why this debt has been incurred.
Include information on how this debt will be repaid.
8.
Include the current amount of your unrestricted funds as of your last Board approved
monthly financial statement.
9.
Provide information on the current litigation, and any financial impact it will have on
your organization.
If your organization has lost funding due to your organization’s capacity to administer the
funds, provide a narrative of the situation, and steps that are being taken to strengthen
your capacity.
21
Form 4 – Due Diligence Review Form
1.
APPLICANT INFORMATION
1(a) How long has your organization been doing
business?
1(b) Number of Employees
Full Time
Part Time
____________ years
Does your organization currently hold 501(c)3 status
with the IRS? ______yes _______no
1(c) Has your organization done business under any other name(s) within the last five years?
If yes, list name(s) used below.
1(d) Is your organization affiliated with or managed by
any other organizations, such as a regional or national
office?
If Yes, provide details.
1(e) Does your organization receive management or
financial assistance from any other organizations?
If Yes, provide details.
Yes
No
Yes
No
1(f) What was your organization’s total revenue in the
most recent 12-month accounting period?
1(g) How many different funding sources does the total
revenue come from?
1(h) Have you been a grantee of the Minnesota
Department of Health within the last five years? If yes,
which division(s) have you received grants from?
1(i) Does your organization have written policies and procedures for the following business
processes?
Accounting
If Yes, please attach a copy of the table of
Yes
No
Not sure
contents.
Purchasing
If Yes, please attach a copy of the table of
Yes
No
Not sure
contents.
Payroll
If Yes, please attach a copy of the table of
Yes
No
Not sure
contents.
2. ACCOUNTING SYSTEM
2(a) Which of the following best describes your organization’s accounting system?
Manual
Automated
22
Combination
2(b) Does the accounting system identify the deposits and expenditures of program funds for
each and every grant separately?
Yes
No
Not sure
2 (c) If your organization has multiple programs within a grant, does the accounting system
record the expenditures for each and every program separately by budget line items?
Yes
No
Not sure
Not applicable
2(d) Are time studies conducted for employees who receive funding from multiple sources?
Yes
No
Not sure
Not applicable
2(e) Does the accounting system have a way to identify over-spending of grant funds?
Yes
No
Not sure
3. FUND CONTROL
3(a) Is a separate bank account maintained for grant funds?
Yes
No
Not sure
3(b) If grant funds are mixed with other funds, can the grants expenses be easily identified?
Yes
No
Not sure
3(c) Are the officials of the organization bonded?
Yes
No
Not sure
4. FINANCIAL STATEMENTS
Did an independent certified public accountant (CPA) ever examine the organization’s
financial statements?____ When? ________________________________________
Yes
No
Not sure
5.
Type of Organization
Government Agency – no documentation required.
Tribal Government – no documentation required.
Non profit or non governmental organization
6.
Type of Documentation – see instructions for requirements
Most recent board-reviewed financial statements Date ______________
Most recent IRS Form 990 Year ___________
Most recent certified financial audit Year _________
23
7.
Describe existing debt
Has any debt been incurred in the last 6 months?
What was the reason for the new debt?
What is the funding source for paying back the new debt?
8.
Unrestricted Funds
Current amount of unrestricted funds
9.
Legal Issues
9 (a) Are there any current or pending lawsuits against the organization?
9(b) If so, would there be an impact on the organization’s financial position?
9(c) Has the organization lost any funding due to accountability issues, misuse, or fraud?
If so, please describe the situation, including when it occurred.
24
Form 5 – MDH Evidence of Compliance with Worker’s Compensation
Minnesota Department of Health
Evidence of Compliance
State law forbids the Commissioner of Health from entering into any grant contract until the Commissioner
receives acceptable evidence of compliance with workers’ compensation insurance coverage requirements
from the grantee. The exception to this requirement is a self-employed grantee that has no employees. An
employee, as defined by M.S. 176.011, subd. 9, is any person who performs services for another for hire,
including minors and family members.
If you do not fall within the exception and you wish to enter into a grant contract with the Commissioner of
Health, you must furnish acceptable evidence of compliance with worker’s compensation coverage in any one
of the following four ways:
1.
Attach a certificate of insurance (supplied by your workers’ compensation carrier) to this Evidence of
Compliance form; or
2.
If you are self-insured, attach to this Evidence of Compliance form, a written order from the Minnesota
Commissioner of Commerce allowing you to self-insure; or
3.
If you are self-insured and you are a state agency or a municipal subdivision of the state, pursuant to
M.S. 176.181, subd. 2, and are not required to obtain a written order from the Commissioner of
Commerce, circle this entire statement and sign and date the form below in the space provided; or
4.
Fill in the information for each item below and sign and date the form in the space provided.
Name and Address of Grantee’s Insurance Carrier:
Grantee’s Insurance Policy Number:
I affirm that all of the employees of __________________________________________
(Grantee’s Name)
are covered by the workers’ compensation insurance policy listed above.
Signed By
Title
Date
25
Form 6 – Assurances and Agreements
BY SIGNATURE, THE AUTHORIZED OFFICIAL AGREES AND ASSURES THAT:
1. Services will be provided in accordance with applicable state and federal laws, rules, requirements,
guidance, and procedures.
2. The agency will comply with state and federal requirements relating to privacy of client information.
3. The agency will comply with the Minnesota Clean Indoor Air Act.
4. The agency (if it has 15 or more employees) or any subcontractors with 15 or more employees will have,
on file and available for submission to Minnesota Department of Health (MDH) upon request, a written
non-discrimination policy.
5. The agency (if it has 15 or more employees) and any subcontractors with 15 or more employees will
disseminate information to beneficiaries and the general public that services are provided in a nondiscriminatory manner in compliance with civil rights statutes and regulations.
6. In fulfilling the duties and responsibilities of this grant, the grantee shall comply with the Americans with
Disabilities Act of 1990, 42 U.S.C. §12101, et seq., and the regulations promulgated pursuant to it.
7. The agency will report accomplishments of the project to the Minnesota Department of Health. Upon
request, the agency will provide additional information needed by the Department for evaluation of the
project's objectives and methods and compliance with any special conditions. The agency will submit an
evaluation work plan within three months of having a fully executed contract.
8. Grant funds shall not be used for purchase of equipment costing more than $5,000.00 per unit and with a
useful life exceeding one year.
9. Grant funds shall not be used for reimbursement for travel and subsistence expenses incurred outside the
state unless it has received prior written approval from the Minnesota Department of Health for such outof-state travel.
10. Grantees shall clearly state in all statements, press releases, requests for proposals, bid solicitations, and
other documents describing projects and programs that the project or program was funded in whole or in
part with money received from the Minnesota Department of Health.
11. Materials developed by grant funds will be part of the public domain and will be accessible to the public as
financially reasonable. Materials developed by the grant funds may be reproduced and distributed by the
grantee to other agencies and providers for a profit so long as the revenues from such sale are credited to
the support of the Preconception Health in Minnesota Grant Program.
12. Information is unbiased, technically accurate, clear and well written, with up- to-date graphics, and
current, reliable sources of information are identified.
13. The agency will comply with all standards relating to fiscal accountability that apply to the
26
Minnesota Department of Health, specifically
A. Budget revisions with justification will be submitted to MDH for prior approval whenever:
(1) changes are made in the project objectives,
or
(2) adjustments are made to line items in the budget approved by the state.
SIGNATURE OF AUTHORIZED PERSON:
Signature:
Title:
Date:
27
Form 7 – Governing Board Resolution
Be it resolved that:
1)
can apply for the Preconception Health in Minnesota Grant
(Agency Name)
Program from the Minnesota Department of Health.
2)
can enter into a grant contract with the Minnesota
(Agency Name)
Department of Health if the application is successful.
3)
is hereby authorized to execute contracts as required to
(Title of Authorized Representative)
implement the organization’s participation in the Preconception Health in Minnesota Grant
Program.
I certify that the above resolution was adopted by the
(Governing Body)
of
on
(Agency Name)
(Date)
Signed:
Witnesses:
__________________________________
(Signature)
________________________________
(Signature)
__________________________________
(Title)
________________________________
(Title)
__________________________________ ________________________________
(Date)
(Date)
28
VIII.
PROJECT NARRATIVE, WORK PLAN and BUDGET
The project narrative and work plan describe your organization and what you intend to
accomplish. To assist you, we have provided detailed instructions on what information should be
included and what grant reviewers will be reviewing in each proposal. The project narrative is
broken into three distinct sections and should be submitted in the same sequence listed below.
1. Organizational Capacity (Form 8)
2. Needs Assessment and Target Population (Form 9)
3. Work Plan: Goals, Objectives, and Activities, Timeline, and Methods of Evaluation
(Form 10)
Form 8 – Organizational Capacity
Using the form, please describe the organizational capacity of your agency
Please keep this section to three (3) typewritten pages or less
A. Background Information on Applicant Agency
 Briefly summarize your agency history including your agency’s mission and
goals.
 Briefly describe the administrative structure of your organization including
structure, services and programs provided, clientele served, geographic
service area (may append a map).
 Describe other key elements that show organizational capacity to provide the
proposed project such as facilities, staffing, cultural competence and readiness
to use funds.
 Provide a summary of relevant training and/or experience of the key persons
who will provide services including their experience or skills in working with
diverse populations.
 Identify the sites where your proposed services will be provided and why you
chose those sites.
 If you are currently providing preconception care or health services in your
organization, please describe how. If you are not currently providing
preconception care, please describe where preconception health care or
services will be incorporated.
If agencies outside the organization will provide contract services, also describe
the administrative structure of the contracting agencies, and their current
experience in preconception health care or services.
B. Evaluation Requirement – Briefly describe the agency’s history of evaluating its
programs and activities. If awarded funds, you must be willing to participate in MDH
required program evaluation activities including the development and implementation
of an evaluation work plan. (See “Program Requirements” section for more
information on the evaluation component)
29
The complete description should include information important for grant reviewers to understand
and assess your organization’s capacity to provide the services.
Criteria for Grant Review: The Organizational Capacity section of the application will be
reviewed and scored according to the following criteria (25 points):
 Does the description give a clear picture of the history, structure, services provided, and
clientele served by the agency?
 Does the agency have a successful history of providing services in Minnesota to women of
child bearing age?
 Does the agency have the capacity (infrastructure, facilities, staffing, cultural competency,
etc.) to deliver the proposed services of routine preconception risk assessment and
counseling, and the proposed interventions in the defined preconception health focus areas?
 Does the agency clearly describe the preconception health services currently provided by
their organization, or any health care or other services that could incorporate a preconception
health component?
 Does the agency have a successful history of evaluating its programs and activities?
30
Organizational Capacity (Form 8)
(Double Spaced – limit this section to 3 pages or less)
31
Form 9 – Needs Assessment and Target Population
Using the form, please describe the need for the project and the target population.
Please limit this section to five (5) typewritten pages or less
A. Assessment of Need
 Describe the demographics of your target population. Provide relevant
population data supporting the nature of the need.
 Describe the risks for preventable birth defects in your target population.
 Describe current preconception health activities that are available in your
community. Please discuss what other agencies or groups are doing in your
community to address preconception health and how you propose to collaborate
with them.
 Identify barriers to preconception health care and other services.
 Detail any racial/ethnic health disparities or health inequities related to
preconception health that exist in your community.
 Explain your plan for authentically engaging with the populations experiencing
health disparities or health inequities that were identified in the needs
assessment including culturally appropriate outreach and services. For authentic
engagement to occur, an agency must ensure that all voices can be heard, that
leadership from the community is valued, that community assets are identified
and leveraged and to the extent possible, community members are included as
decision makers. It means forming collaborations with community members and
agencies in authentic ways that respect, appreciate and value their input.
 Describe how you will serve clients when English is a second language.
 In a Statement of Need, summarize the need for preconception health care or
other services in your agency and community. Include the need for:
a. Preconception risk assessment screening, counseling, and referral, and
b. The chosen preconception health focus area(s) (Appendix B).
The complete description should include information important for the grant reviewers to
understand your target population, community assets and unmet needs.
Criteria for Grant Review: The Statement of Need section of the application will be
reviewed and scored according to the following criteria (25 points):
 Does the applicant clearly identify their target population and why they are suited to provide
services to that target population?
 Does the applicant describe the risks for preventable birth defects in the target population?
 Does the applicant clearly describe any preconception health activities available in their
community?
 Does the applicant clearly describe barriers to preconception health care and other services in
their community?
 Does the applicant clearly describe any racial/ethnic disparities or health inequities related to
preconception health in their community?
32
Criteria for Grant Review: The Statement of Need section of the application will be
reviewed and scored according to the following criteria (25 points):
 Does the applicant have a plan to authentically engage with populations experiencing health
disparities or inequities for preconception health that includes culturally appropriate outreach
and services?
 Does the applicant articulate a clear Statement of Need for providing routine preconception
risk assessment, counseling, referral and preconception health interventions?
33
Need Assessment and Target Population (Form 9)
(Double Spaced – limit this section to 5 pages or less)
34
Form 10 – Work Plan
Interventions must be evidence-based practices or programs.
Definition: Evidence-Based Practices Evidence-based practices are the systematic selection,
implementation, and evaluation of strategies, programs and policies with evidence from
scientific literature that they have demonstrated effectiveness in accomplishing intended
outcomes. Evidence-based practices are skills, techniques, and strategies that can be used by a
practitioner. Evidence-based programs consist of collections of practices that are done within
known parameters (philosophy, values, service delivery structure, and treatment components)
and with accountability to the consumers and funders of those practices.4
Examples of evidence-based practices and programs that may be included as part of program
activities can be found in appendix C and additional resources for acceptable programs or tools
can be found in appendix D. Applicants may also propose interventions not included in this list,
with adequate explanation of the evidence that currently exists to support those interventions.
An intervention may be considered evidence-based if it meets the following criteria:
1.
2.
3.
4.
The intervention is supported by federal groups as being evidence-based practice
The intervention is reported (with positive effects) in peer-reviewed journals
The intervention demonstrates/shows promise of improved outcomes in a practice setting
The intervention is based on clinical practice guidelines
Complete all of the following on Work Plan Form 10. An example of a Work Plan can be found
following these instructions. The work plan should be for the entire two year grant period.
Using the form, please describe your proposed project. This information should be
consistent with the Project Abstract (Form 2) you completed.
This form is a word document and will expand to accommodate your writing. Please
complete the entire form and provide enough information for the reviewers to understand
your proposed project. This section can be as long as needed to explain your proposed
activities over the two year grant period.
A. Work Plan: Goals
Provide the goals for your project that will be funded by the Preconception Health in
Minnesota Grant Program. One goal should be related to implementing preconception
risk screening/assessment and counseling in your organization. One goal should be
included for each of your selected preconception health focus area(s) (see Appendix
B).
4
(Fillmore-Houston CHB)
35
A goal describes the purpose toward which your efforts are directed. Goals indicate
the desired outcomes for the community’s health status. Goals are long-range and
broad in scope. A goal may or may not be measurable.
B. Work Plan: Measurable Objectives
On the Work Plan, list your intended objectives to meet your goals. Write objectives
for the two year period July 1, 2014 through June 30, 2016.
Include objectives for each stated goal. Objectives are tangible, measurable and
achievable outcomes specific to what the proposed grant project is intending to
accomplish. Objectives that use a number or percentage as an ending outcome should
include the current base level number or percentage so that the intended change is
clear. It is expected that the grant project and objectives will be achieved within the
grant period.
Objectives pertain to what will happen within the target population, not what the
clinic will “do” (activities within the work plan). Objectives contain four common
elements:
1.
2.
3.
4.
An indicator (how the problem will change)
A target (a “who” or a “what,” generally the client)
A time frame (when), and
The amount of measurable change expected in the indicator, or the target.
A common format for objectives is as follows:
By (insert when), there will be (insert % or # of change), of (insert what
population) (insert indicator – do what/change how)
For example:
By June 30, 2016, there will be an increase of 10% from 30% of women
(when?)
(% of change)
(baseline)
clients in Healthy Clinic who report taking a multi-vitamin or folic acid
(what population)
(indicator – do what/change how)
supplement with at least 400 mcg of folic acid every day.
Following this format, each objective will include in its statement a measurable
outcome.
36
C. Work Plan: Objective Rationale
For each objective, describe on the work plan in 250 words or less why this objective
was chosen to meet your stated goal. Discuss the evidence from research or practice
that supports the interventions that you will use as part of this project. Include
appropriate literature citations and cite the sources you have used. If the proposed
intervention is not included in appendices C or D, please include an adequate
explanation of the evidence that currently exists to support those interventions.
If there is not enough room in the table for the rationale, the evidence may be
footnoted.
D. Work Plan: Target Population:
List the target population for each objective. The target population must be nonpregnant women of reproductive age and can include their partners. In addition, the
target population should be specific to the populations identified in your needs
assessment. Key audiences for this grant are those women experiencing racial and
ethnic disparities in health status or health inequities.
E. Work Plan: Implementation Activities
List the activities that you will use to meet your objectives in the first left column in
the table. List the activities in logical and chronological sequence. Activities should
be evidence-based practices and programs, and culturally appropriate. Applicant
should propose solutions to overcome the barriers to services previously identified in
the needs assessment.
F. Work Plan: Activity Rationale
For each activity, briefly describe on the work plan form why the activity was chosen,
why it is likely to be effective, and why you think it will assist you in meeting your
objective.
If appropriate, include information about how the activities will address barriers
previously identified in the needs assessment.
G. Work Plan: Timeline
List when the activities for this project expect to be implemented and completed.
Please consider that the grant period is for two years (July 1, 2014 – June 30, 2016).
H. Work Plan: Evaluation Methods
In the evaluation column, list the proposed methods of evaluating your objectives.
Clearly state process and outcome measures that you will use to evaluate progress
toward meeting each of your stated objectives. If you are awarded a grant, you will be
expected to report the progress on your work plan and your evaluation measures on a
quarterly basis.
Process evaluation measures must be identified for each activity and at a minimum
must include the following information:
37


Number of clients receiving preconception risk assessment and counseling,
and by age, race/ethnicity, and educational attainment if possible.
Number of clients receiving your chosen project interventions, and by age,
race/ethnicity, and educational attainment if possible.
If awarded funds, other process measures for the state level cross-site evaluation
will be required by the state depending on your focus areas.
Outcome evaluation measures at a minimum should include:
 A measure to assist in determining the effectiveness of the program in
reaching the objectives you established and in addressing the stated need.
 Some activities will have outcome measures because of their importance in
achieving the objective. Therefore, you should include at least one outcome
measure among all activities for each objective.
The evaluation data will be used to determine if changes or adjustments are needed
in the program as it proceeds.
If awarded funds, with MDH assistance, you will be required to provide MDH with a
separate evaluation plan described in section VI, Program Requirements.
Provide enough information in your work plan to answer the questions in the Criteria
for Grant Review below.
38
Criteria for Grant Review: The Project Work Plan section of the application will be
reviewed and scored according to the following criteria (40 points):
 Does the applicant provide clear goals for the preconception risk assessment and counseling
and proposed interventions?
 Does the applicant clearly describe the components of the routine preconception risk
assessment and counseling they propose to provide?
 Does the applicant clearly describe the preconception health interventions they propose to
provide?
 Does the applicant propose solutions to overcome the identified barriers to these services?
 Did the applicant cite the available professional literature demonstrating how the proposed
activities/strategies for each objective have been proven or are likely to be effective with the
target population?
 Are the proposed objectives for each component clearly described, including a time frame
(“when”), the target population (“who”), and “amount of change expected (“what”)?
 Are the proposed activities/strategies for each Objective consistent with the cultural and
socioeconomic characteristics of the target population and demonstrate cultural
appropriateness?
 Do the proposed activities address the identified health disparities and inequities of the target
population?
 Based on the evidence provided, are the proposed activities/strategies for each Objective
proven or likely to be effective with the target population?
 To what extent is the project likely to meet its objectives in the grant cycle (i.e. feasibility)?
 To what extent do the proposed evaluation criteria effectively measure the project’s progress
toward meeting the objectives?
 Overall, is the work plan sufficiently detailed, clear and easy to understand and does it
demonstrate a clear relationship between the identified problem and the goals, objectives, and
activities?
39
EXAMPLE
WORK PLAN 2014-2016 Form 10
Healthy Family Planning Clinic
GOAL #1: To reduce the risk of women in Purple County of having a baby with neural tube defect by assuring that all women
of reproductive age have adequate folic acid intake.
Two Year Objective #: 1 By June 30, 2016, there will be an increase from 30-40% of women clients in the Healthy Family Planning
clinic who report taking a daily multi-vitamin or folic acid supplement with 400 mcg of folic acid at least daily.
Objective Rationale: (250 words or less)
This objective was chosen because the U.S. Public Health Service recommends that all women of childbearing age consume 400
micrograms of folic acid each day in order to reduce the risk of a pregnancy affected by a neural tube birth defect.
http://www.uspreventiveservicestaskforce.org/uspstf09/folicacid/folicacidrs.htm. Currently only 30% of women seen at the clinic are
taking a multi-vitamin or folic acid supplement (400 mcg) on a daily basis. Almost all clients are sexually active. Research has shown
that women are more likely to take a folic acid supplement when they are directed to do so by their physician
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5113a1.htm. Providers will be trained on the importance of daily folic acid intake.
They will be encouraged to assess the client’s intake, and while providing to patients, a “prescription,” review information about the
importance of folic acid/folate intake. This “prescription”, along with education from the provider, will serve as a reminder to clients to
take folic acid regularly. All educational materials will be translated into Spanish and a bilingual health educator will be available. The
target population was chosen because according to MN PRAMS data these populations were significantly less likely to take folic acid
daily prior to pregnancy.
Target Population: Women of reproductive age who seek care at Healthy Family Planning clinic and who are less than 22 years of age,
low income and Hispanic.
40
ACTIVITIES (steps, activities,
tasks to achieve objective
Activity Rationale
Timeline
Start
Timeline
finish
Process Evaluation
Measures
(one for each
activity)
Outcome Evaluation
Measures
(encouraged to have more
than one for each
objective)
Develop a folic acid
“prescription” pad including
method (folic acid supplement,
multivitamin, fortified cereal)
and directions (ex. Daily after
brushing teeth, with lunch, etc.)
 Distribute “prescription pad
to providers
The written
“prescription” pad will
serve as a reminder to
providers to talk with
their clients about folic
acid and a reminder to the
patients to take a
supplement or eat
fortified foods daily
The training will stress
the importance of daily
folic acid consumption.
This will encourage
providers to use the
“prescription”.
8/14
9/14
“Prescription” Pad
developed and
distributed to
provider
N/A
10/14
ongoing
10/14
12/14
9/14
10/14
9/14
10/14
10/15
10/15
Train providers to write out and
hand over a folic acid
prescription and discuss folic
acid guidelines and
supplementation for all nonpregnant female clients of
reproductive age.
 Develop training plan
Hold folic acid training brown
bags for nurses and educators
to review folic acid guidelines
on a yearly basis
-train new staff on an ongoing
basis
Develop method to measure
client baseline folic acid intake
and after provider training , e.g.
chart audits either by hand or
using EHR
Nurses and educators
play a key role in patient
education. Providing
training annually reminds
them of the importance of
folic acid
supplementation.
Same as above
41
Number of providers % of charts indicating
trained.
provider discussed folic
acid guidelines and
supplementation during
client visits and handed
out “prescription” at
baseline, after training,
and every six months.
Number and job role % of staff trained that
of staff trained
indicated a knowledge
gain on a pre/post test
ongoing
9/14
ongoing
% of client charts
indicating use of folic
acid supplementation on a
daily basis at baseline,
after training and every 6
months.
Form 10
(NO PAGE LIMIT)
Preconception Health in Minnesota Grant Program Work Plan 2014-2015
Name of applicant agency
GOAL:
Two Year Objective #1:
Objective Rationale: (250 words or less)
Target Population:
ACTVITIES (steps, activities,
tasks to achieve objective)
Activity Rationale
Timeline
Start
.
.
.
Repeat table for each objective
42
Timeline
Finish
Process Evaluation
Measures (one for
each activity)
Outcome Evaluation
Measures (encouraged to
have more than one for
each objective)
Form 11 – Budget Justification
Use Form 11 to prepare a budget justification for this grant project. The budget justification
should include an explanation for each of the cost items for which grant funds are being
requested. Explanations for each cost item should include details on how the budgeted cost items
were calculated as well as rationale of how the item relates to the objectives and activities listed
in the Work Plan.
The form requests information for budgeted amounts and budget justifications for those amounts.
Please complete a separate budget and justification sheet for Year 1 (July 1 2014– June 30, 2015)
and for Year 2 (July 1, 2015 – June 30, 2016). Additional instructions can be found on the Form
11 – Yr. 1 and Form 11 Yr. - 2
A. Salary and Fringe
For staff supported by this grant request, list each name and/or position, salary and
percent of time and fringe benefits. Provide a breakdown of what is included in the fringe
rate (example: The 31.8% fringe rate breakdown is 6.20% FICA, 1.45% Medicare, 5%
Retirement and 19.15% Insurance).
B. Contractual Services
List the services you expect to contract out, the contractor’s or consultant’s name,
whether the contractor is non-profit or for-profit, the length of time the services will be
provided and the total amount you expect to pay. Supplies and travel should be included,
if applicable. Itemize equipment rented or leased if applicable.
C. Travel
Provide the number of miles of travel planned for project activities as well as the rate of
reimbursement per mile. (Note: Out-of-state travel is discouraged, and must be approved
specifically by the MDH grant manager). The rationale should specify how the travel will
support activities and objectives. Please consider two (2) trips to St. Paul Minnesota for
grantee meetings for the grant cycle. Explain your expected travel costs, including
mileage, hotel and meals. If the project will have additional travel, itemize the costs,
frequency and the nature of the travel.
D. Supplies and Expenses
Briefly explain the expected costs for items and services you will purchase to run your
program. List office and program supplies and expendable equipment such as training
materials, curriculum or software. Generally supplies include items that are consumed
during the course of the program and other direct costs as needed.
E. Other Expenses
Briefly describe any expenses that do not fit in any other category.
F. Evaluation
A minimum of 5% of the grant expenses must be included in the budget for evaluation
costs. An evaluation plan that includes more details as to how the 5% or more of funds
43
will be allocated will be required from all grantees if awarded funds. It is not necessary to
include any additional information in the budget justification on the evaluation at this
time.
G. Administrative Costs
Administrative costs are defined as “costs that represent the expenses of doing business
that are not easily identified with a particular grant, contract, project, function or activity
but are necessary for the general operation of the organization and the conduct of
activities it performs. Complete the Administrative Cost Allocation Questionnaire (Form
13) and if Applicable, the Administrative Cost Allocation Worksheet (Form 14). If
applicable, enter the Administrative cost rate below and the amount of the administrative
cost being requested in the box to the right.
44
Form 11 – Budget Justification – Yr. 1
Preconception Health in Minnesota Grant Program
Applicant Agency:
Contact Person:
Phone Number:
Email Address:
Budget Period: July 1, 2014 – June 30, 2015
Revision # (MDH use only) __________________________________
Salary and Fringe Benefits:
For staff supported by this grant request, list each name and/or position, salary
and percent of time and fringe benefits. Provide a breakdown of what is
included in the fringe rate (example: The 31.8% fringe rate breakdown is
6.20% FICA, 1.45% Medicare, 5% Retirement and 19.15% Insurance)
Budget Justification:
REQUESTED
DOLLARS
Total Salary and Fringe:
Contractual Services:
List the services you expect to contract out, the contractor’s/consultant’s name,
whether the contractor is non-profit or for-profit, the length of time the services
will be provided and the total amount you expect to pay. Supplies and travel
should be included, if applicable. Itemize equipment rented or leased for the
project.
Budget Justification:
REQUESTED
DOLLARS
Total Contractual Services:
Travel:
Please consider two (2) trips to St. Paul Minnesota for grantee meetings for the
grant cycle. Explain your expected travel costs, including mileage, hotel and
meals. If the project will have additional travel, itemize the costs, frequency
and the nature of the travel.
Budget Justification:
Total Travel:
45
REQUESTED
DOLLARS
Supplies and Expenses:
Briefly explain the expected costs for items and services you will purchase to run your
program. Include telephone expenses that are part of your proposal; cell phones and
new telephone equipment to be purchased, if applicable. Estimate postage if it is part
of the project. List any printing and copying costs necessary for the project (other than
occasional copying on an office copy machine). List office and program supplies and
expendable equipment such as training materials, curriculum and software. Generally
supplies include items that are consumed during the course of the project, equipment
under $5,000 and items such as additional rent for program space, participant
transportation, participant training and other direct costs as needed.
REQUESTED
DOLLARS
Budget Justification:
Total Supplies and Expenses:
Other Expenses:
Briefly describe any expenses that do not fit in any other category.
REQUESTED
DOLLARS
Budget Justification:
Total Other Expenses:
SUBTOTAL (Enter subtotal of expenses form all previous categories):
SUBTOTAL
Evaluation:
A minimum of 5% of grant expenses must be included in the budget for
evaluation costs. Multiply the amount of the subtotal by 5% or the percent
included for evaluation, and enter here. It is not necessary to include any
additional information on evaluation procedures in this form at this time.
Evaluation:
REQUESTED
DOLLARS
DIRECT COST TOTAL (Subtotal + Evaluation)
Direct Cost Total:
Administrative Costs:
Complete the Administrative Cost Allocation Questionnaire (Form 13) and if
Applicable, the Administrative Cost Allocation Worksheet (Form 14). If applicable,
enter the Administrative cost rate below and the amount of the administrative cost
being requested in the box to the right.
Administrative Total:
GRANT FUNDS TOTAL:
46
REQUESTED
DOLLARS
Form 11 – Budget Justification – Yr. 2
Preconception Health in Minnesota Grant Program
Applicant Agency:
Contact Person:
Phone Number:
Email Address:
Budget Period: July 1, 2015 – June 30, 2016
Revision # (MDH use only) __________________________________
Salary and Fringe Benefits:
For staff supported by this grant request, list each name and/or position, salary
and percent of time and fringe benefits. Provide a breakdown of what is
included in the fringe rate (example: The 31.8% fringe rate breakdown is
6.20% FICA, 1.45% Medicare, 5% Retirement and 19.15% Insurance)
Budget Justification:
REQUESTED
DOLLARS
Total Salary and Fringe:
Contractual Services:
List the services you expect to contract out, the contractor’s/consultant’s name,
whether the contractor is non-profit or for-profit, the length of time the services
will be provided and the total amount you expect to pay. Supplies and travel
should be included, if applicable. Itemize equipment rented or leased for the
project.
Budget Justification:
REQUESTED
DOLLARS
Total Contractual Services:
Travel:
Please consider two (2) trips to St. Paul Minnesota for grantee meetings for the
grant cycle. Explain your expected travel costs, including mileage, hotel and
meals. If the project will have additional travel, itemize the costs, frequency
and the nature of the travel.
Budget Justification:
Total Travel:
47
REQUESTED
DOLLARS
Supplies and Expenses:
Briefly explain the expected costs for items and services you will purchase to run your
program. Include telephone expenses that are part of your proposal; cell phones and
new telephone equipment to be purchased, if applicable. Estimate postage if it is part
of the project. List any printing and copying costs necessary for the project (other
than occasional copying on an office copy machine). List office and program supplies
and expendable equipment such as training materials, curriculum and software.
Generally supplies include items that are consumed during the course of the project,
equipment under $5,000 and items such as additional rent for program space,
participant transportation, participant training and other direct costs as needed
REQUESTED
DOLLARS
Budget Justification:
Total Supplies and Expenses:
Other Expenses:
Briefly describe any expenses that do not fit in any other category.
REQUESTED
DOLLARS
Budget Justification:
Total Other Expenses:
SUBTOTAL (Enter subtotal of expenses form all previous categories):
SUBTOTAL
Evaluation:
A minimum of 5% of grant expenses must be included in the budget for
evaluation costs. Multiply the amount of the subtotal by 5% or the percent
included for evaluation, and enter here. It is not necessary to include any
additional information on evaluation procedures in this form at this time.
Evaluation:
REQUESTED
DOLLARS
DIRECT COST TOTAL (Subtotal + Evaluation)
Direct Cost Total:
Administrative Costs:
Complete the Administrative Cost Allocation Questionnaire (Form 13) and if
Applicable, the Administrative Cost Allocation Worksheet (Form 14). If applicable,
enter the Administrative cost rate below and the amount of the administrative cost
being requested in the box to the right.
Administrative Total:
GRANT FUNDS TOTAL:
48
REQUESTED
DOLLARS
Form 12 – Budget Summary
Form 12 is the Budget Summary Sheet and should be completed on the provided form. Using
the form, please complete the two-year budget summary showing how requested funds will
support the proposed project over the two year grant period.
For each line item, enter the total number of funds you plan to spend over the two year grant
cycle. This number is obtained by adding the figures from the Dollars Requested boxes on the
Forms 11: Budget Justification forms completed for Year 1 and Year 2.
Criteria for Grant Review: The Budget section of the application will be reviewed and
scored according to the following criteria (10 points):
 Are Budget Justifications (Forms 11) and Budget Summary (Form 12) complete?
 Do the amounts on the Budget Justifications (Forms 11) match the Budget Summary
(Form 12)?
 Is the information contained in the Budget Justification consistent with what is proposed
in the Work Plan?
 Are the projected costs reasonable and sufficient to accomplish the proposed activity?
49
Form 12 – Budget Summary Sheet
Two year grant period
Preconception Health in Minnesota Grant Program
Applicant Agency:
Contact person for further information:
Phone:
Email address:
Grant Funds Requested
Total Dollars for July 1, 2014 – June 30,
2016
Budget by Line Item
Salaries and Fringe
$
Contractual Services
$
Travel Expenses
$
Supplies and Expenses*
$
Other Expenses
$
Sub Total
$
* Includes telephone, postage, print, copy, and equipment under $5,000.00
5% Evaluation
Direct Cost Total
(Subtotal +Evaluation)
Administrative Costs
(Refer to Form C)
$
GRANT TOTAL FUNDS
$
$
$
50
Form 13 – Administrative - Indirect Cost Allocation for CYSHN Section Grants
Please complete this form.
Grantee Agency:
CYSHN Program: Preconception Health in Minnesota Grant Program.
Please check one of the four options:
1. Not applicable – No charges to MDH Preconception Health in Minnesota Grant
Program are for administrative-indirect cost.
2. Indirect Cost Rate Agreement – A Federal negotiated fixed rate is to be charged
against all participating programs, including CYSHN grant program.
A signed agreement covering the current Federal fiscal year is attached.
3.
Approved Cost Allocation Process:
Option 1 –Administrative - indirect costs are allocated to the agency’s programs
using worksheets developed by the agency for this purpose. Agency worksheets and
supporting documents are attached which are in compliance with the requirements of
the OMB Circular A-87 “Cost Accounting Principles for State, Local, and Indian
Tribal Governments” and the Federal award(s) for which they apply
4.
CYSHN Grant Program - Approved Cost Allocation Process:
Option 2 –Administrative - indirect costs are allocated to the agency’s programs
using the optional Administrative – Indirect Cost Allocation Worksheets on the
following page.
CYSHN worksheets and supporting documents are attached which are in
compliance with the requirements of the OMB Circular A-87 “Cost
Accounting Principles for State, Local, and Indian Tribal Governments” and the
Federal award(s) for which they apply.
Budgets will not be approved until all required supporting documents have been submitted and
accepted.
51
Form 14 – Administrative – Indirect/Cost Allocation Worksheet
Please complete this form.
Grantee Name: _________________________________________________
1. Cost item included in the administrative-indirect rate on this worksheet:
[Examples include rent, telephones, supplies, etc.]
2. Total cost of items in 1 to the agency:________________________________________
3. The CYSHN grant program share of the total cost is calculated through use of (check one):
a.
b.
c.
CYSHN grant program percent of the total agency staff hours or full-time
employees (FTE’s) (Cannot use staff salary dollars.)
CYSHN grant program percent of the total square feet of space occupied by the
agency.
Other – specify:
And is in compliance with the requirements of the OMB Circular A-87 “Cost
Accounting Principles for State, Local, and Indian Tribal Governments”, and the
Federal award(s) for which they apply.
4. Calculation of the CYSHN grant program percentage:
Programs operated by the
agency.
Each program’s staff hours,
FTE’s, (cannot use staff
salary dollars) square feet,
or other (cannot use total
program dollars). Circle the
criteria you are using.
TOTAL:
5.
Calculation of each
program’s percent of the total
(calculated to the nearest
tenth percent, e.g., 5.2%).
100%
CYSHN grant program proportionate amount:_____________________________
52
References
Barber, C., Harvey, J., & Punyko, J. (2011, September 19). Preconception Health Measures of
Minnesota Women: An Analysis of Minnesota Pregnancy Risk Assessment Monitoring
System (PRAMS) 2007-2008. The Deborah E. Powell Center for Women’s Health 8th
Annual Women’s Health Research Conference.
Fillmore-Houston Community Health Board
http://www.health.state.mn.us/divs/opi/pm/lphap/qiplan/docs/fillmorehouston/g_glossary.
pdf; adapted from Public Health accreditation Board Glossary found at:
http://www.phaboard.org/wp-content/uploads/PHAB-Acronyms-and-Glossary-of-TermsVersion-1.0.pdf (adapted from: Brownson, Fielding and Maylahn. Evidence-based Public
Health: A Fundamental Concept for Public Health Practice. Annual Review of Public
Health).
Minesota Department of Health Center for Health Statistics. (2011). Minnesota VitalSigns Vol. 7,
No.1. St. Paul: MDH.
http://www.health.state.mn.us/divs/chs/vitalsigns/2010natmorttrends.pdf Accesssed
12/12/13
NCBDDD, CDC. (2006, April 12). What is Preconception Care? National Center on Birth
Defects and Developmental Disabilities, CDC: http://archive.is/7GQuJ Accessed
12/12/13
NCBDDD, CDC. (2006, April 12). Why is Preconception Care a public health concern?,
Preconception, National Center on Birth Defects and Developmental Disabilities, CDC:
http://archive.is/YWiJn Accessed 12/12/13
Report of the Secretary’s Advisory Committee on Infant Mortality: Recommendations for HHS
Action and Framework for a National Strategy; January 2013.
http://www.hrsa.gov/advisorycommittees/mchbadvisory/InfantMortality/Correspondence/
recommendationsjan2013.pdf Accessed 12/6/13
U.S. Department of Health and Human Services. (2011, December 16). Healthy People 2020Improving the Health of Americans. http://www.healthypeople.gov/2020/default.aspx
Accessed 12/6/13
53
Appendices
Appendix A:
Criteria for Scoring
Appendix B:
Preconception Health Focus Areas
Appendix C:
Focus Area Interventions Risk Factors
Appendix D:
Resources and References
Appendix E:
PRAMS Research
54
Appendix A – Preconception Health in Minnesota Criteria for Grant Review Score Sheet
Overview:
The following review score sheet is designed to assist you with scoring the applicant's proposal. Please use one of these forms for each
grant you are scoring. Use the questions in each area as a guide for scoring. Please write comments in the space provided, it may help
you remember key points when the proposals are being discussed at the review team meeting. Although each section references a specific
form, please base your scores on information provided in any area of the application. Be sure to total the points in each section (in the
spaces provided). Review Team sessions are conducted as public meetings. All written information from the review score sheets and
discussions are public information.
For Reviewers Only: Total the points for this application below when your review is complete.
Total possible points
for each section
Final Score
25
Organizational Capacity (Form 8)
25
Needs Assessment and Target Population (Form 9)
40
Work Plan (Form 10)
10
Budget Justification and Summary (Forms 11 and 12)
Total Points: 100
Funding Recommendation
Check the appropriate box:
__ Fund
__Fund with special considerations (describe special considerations):
__Do not fund (describe reason for not funding):
55
Organizational Capacity (Form 8)
Possible Points
Does the description give a clear picture of the
history, structure, services provided, and clientele
served by the agency?
5
Does the agency have a successful history of
providing services in Minnesota to women of child
bearing age?
5

Does the agency have the capacity (infrastructure,
facilities, staffing, cultural competency, etc.) to
deliver the proposed services of routine
preconception risk assessment and counseling, and
the proposed interventions in the defined
preconception health focus areas?

Does the agency clearly describe the preconception
health services currently provided by their
organization, or any health care or other services that
could incorporate a preconception health component?
6
5
4
Comments (Strengths &
Weaknesses)
Criteria
Does the agency describe how it evaluates its
programs and activities?
Total possible points: 25
Organizational Capacity Total Points
56
Points Awarded
Needs Assessment and Target Population (Form 9)
Possible Points
4
2
2
3
5
5
4
Total possible points: 25
Criteria
Comments (Strengths &
Weaknesses)
Does the applicant clearly identify their target
population and why they are suited to provide
services to that target population?
Does the applicant describe the risks for preventable
birth defects in the target population?
Does the applicant clearly describe any
preconception health activities available in their
community?
Does the applicant clearly describe barriers to
preconception health care and other services in their
community?
Does the applicant clearly describe any racial/ethnic
disparities or health inequities related to
preconception health in their community?
Does the applicant have a plan to authentically
engage with populations experiencing health
disparities or inequities for preconception health that
includes culturally appropriate outreach and services?
Does the applicant articulate a clear Statement of
Need for providing routine preconception risk
assessment and counseling and preconception health
interventions?
Needs Assessment and Target Population Total Points
57
Points Awarded
Work Plan (Form 10)
Possible Points
2
3
4
3
3
3
5
4
Criteria
Does the applicant provide clear goals for the
preconception risk assessment and counseling and
proposed interventions?
Does the applicant clearly describe the components
of the routine preconception risk assessment and
counseling they propose to provide?
Does the applicant clearly describe the
preconception health interventions they propose to
provide?
Does the applicant propose solutions to overcome
the identified barriers to these services?
Did the applicant cite the available professional
literature demonstrating how the proposed
activities/strategies for each objective have been
proven or are likely to be effective with the target
population?
Are the proposed Objectives for each component
clearly described, including a time frame (“when”),
the target population (“who”), and “amount of
change expected (“what”)?
Are the proposed activities/strategies for each
Objective consistent with the cultural and
socioeconomic characteristics of the target
population and demonstrate cultural
appropriateness?
Do the proposed activities address the identified
health disparities and inequities of the target
population?
58
Comments (Strengths &
Weaknesses)
Points Awarded
Possible Points
4
3
3
3
Criteria
Comments (Strengths &
Weaknesses)
Based on the evidence provided, are the proposed
activities/strategies for each Objective proven or
likely to be effective with the target population?
To what extent is the project likely to meet its
objectives in the grant cycle (i.e. feasibility)?
To what extent do the proposed evaluation criteria
effectively measure the project’s progress toward
meeting the objectives?
Overall, is the work plan sufficiently detailed, clear
and easy to understand and does it demonstrate a
clear relationship between the identified problem
and the goals, objectives, and activities?
Total possible points: 40
Work Plan Total Points
59
Points Awarded
Budget Justification and Summary (Forms 11 and 12)
Possible Points
2
2
3
3
Comments (Strengths &
Weaknesses)
Criteria
Are Budget Justifications (Forms 11) and Budget
Summary (Form 12) complete?
Do the amounts in the Budget Justifications (Forms
11) match the Budget Summary (Form 12)?
Is the information contained in the Budget
Justification consistent with what is proposed in the
Work Plan?
Are the projected costs reasonable and sufficient to
accomplish the proposed activity?
Total possible points: 10
Budget Justification and Summary Total Points
60
Points Awarded
Appendix B – Preconception Health Focus Areas
Preconception Health Focus Areas
Activities directed to non-pregnant women of reproductive age
Routine Risk Assessment of Preconception Health Status
(including family history), Counseling and Referral
Reproductive Health
A. Reproductive Life
Plans
B. Planned PregnancyEnsuring adequate
pregnancy intervals
. Substance Use and Exposure
A. Alcohol
B. Tobacco
C. Illicit or “street” drugs
Avoidance of alcohol,
tobacco, and illicit or “street
drugs”.
D. Teratogenic Medications
avoidance of teratogenic
medications and other
medications affecting birth
outcomes including epilepsy
medications
E. Environmental Exposures
avoidance of contact with
chemicals and other
chemicals that might result
in certain birth defects.
. Nutrition & Weight
A. Folic Acid/Folate intake
Supplementation/folate
intake prior to pregnancy;
B. Obesity/Overweight
Maintaining or achieving a
healthy pre-pregnancy
BMI (Healthy weight)
61
. Chronic Disease
A. Diabetes
Ensuring women with
diabetes are in good glycemic
control before and during
pregnancy. Education about
teratogenic medications
related to diabetes.
B. Hypertension
Management of hypertension
before and during pregnancy.
Education about teratogenic
medication related to
hypertension.
Appendix C – Preconception Health Risk Assessment & Focus Area Interventions5
Intervention
Risk
Positive steps a woman can take
Examples of interventions
Preconception
Health Risk
Assessment,
Counseling and
Referral
As a part of client interaction and/or
visit, provide preconception risk
assessment through screening to
identify preconception health risk
factors.
Complete a preconception health risk
assessment tool at least annually and
follow up on any suggested referrals.
Work with a clinic to incorporate a
preconception health risk assessment
tool into the electronic health (EHR)
record so that it becomes a routine
part of clinical care.
Provide educational and health
promotion counseling to all women
of childbearing age to reduce
reproductive risks and improve
pregnancy outcomes.
Incorporate a Preconception Health
Omaha Pathway into the agency’s
EHR so that it becomes a standard of
practice for local public health
agencies.
Adapt already existing or develop
risk assessment tool.
Incorporate family history and
heredity disorders questions into
preconception health risk assessment
tool.
Family History
5
Women who have someone in their
family with a birth defect have a
higher chance of having a child with
Learn about your family history
including inheritable conditions that
impact birth outcomes.
See Appendix D for resource, references and additional suggested interventions
62
Develop protocol for counseling and
referral based on results of
preconception health risk assessment.
Incorporate referrals to genetic
counselors into routine care.
Intervention
Risk
Positive steps a woman can take
Examples of interventions
a birth defect.
If you have a personal or family
history of birth defects, counseling
by a clinical geneticist or genetic
counselor and testing may be
recommended.
Work with providers to incorporate
family history into risk assessment,
screening and counseling.
Focus Area
Risk
Positive steps a woman can take
Examples of interventions
Reproductive
health
Shorter birth intervals are associated
with an increased risk of
gastroschisis.
Reproductive Life
Planning
Fifty percent of pregnancies are
unplanned and can happen at a time
when a woman’s health or social
situation is not ideal. A reproductive
life plan can help ensure that the
woman is healthy and ready if she
chooses to get pregnant.
Complete a reproductive life plan. A
reproductive life plan is important for
a woman’s personal well-being,
whether or not she plans to have
children. Planning if and when to
have children helps a woman think
about how she wants to live her life
and achieve her goals. The plan could
also be completed with her partner.
Provide reproductive life planning
tools for women of reproductive age
and their partners. This includes
discussing the use of family planning
methods to ensure adequate
interpregnancy birth intervals. These
funds cannot be used to provide
prescription contraceptives.
However, referrals for needed health
and social services as determined by
the results of the needs assessment
are encouraged.
Planned Pregnancy –
ensuring adequate
pregnancy intervals
Choose healthy habits, live well, and
feel good about your life.
Ensure adequate interpregnancy
intervals.
Development or adaptation of a
reproductive life plan that contains
key factors and respects variations in
age; literacy including health
literacy; and cultural/linguistic
contexts for use in already existing
programs.
Reproductive life planning can be
incorporated into electronic health
records of clinics or local public
health and used with individual
patient/client visits. The tool can be
used as part of community education
programs. Good health habits can be
63
Focus Area
Substance Use and
Exposure
Alcohol
Risk
Drinking during pregnancy may
cause a baby to be born with a fetal
alcohol spectrum disorder, heart and
growth problems, and cognitive and
behavioral impairment.
Heavy alcohol use before pregnancy
is predictive of continued use during
pregnancy.
Positive steps a woman can take
Avoidance of alcohol, tobacco, and
illegal or “street” drugs.
There is no safe level of alcohol
consumption during pregnancy.
Women should not drink if they are
planning to become pregnant or are
sexually active and do not use
effective birth control.
In Minnesota; about 2 in 3 women
(67 percent) reported drinking
alcohol in the 3 months before
pregnancy.
Tobacco
Examples of interventions
included as part of reproductive life
planning.
Encourage providers to ask at every
opportunity about alcohol use,
document drinking patterns
(frequency and amount) and
encourage positive behaviors.
Implementation of CHOICES: A
Program for Women About Choosing
Healthy Behaviors
http://www.cdc.gov/ncbddd/fasd/doc
uments/choices_onepager_april2013.pdf.
The Centers for Disease Control and
Prevention and the American College
of Obstetricians and Gynecologists
(ACOG), have developed the
Drinking and Reproductive Health: A
Fetal Alcohol Spectrum Disorders
Prevention Tool Kit. (Centers for
Disease Control and Prevention,
2010).
http://www.cdc.gov/ncbddd/fasd/rese
arch-preventing.html
Smoking during pregnancy can
Stopping smoking prior to
increase risks for certain heart defects pregnancy.
and cleft lip or cleft palate.
In Minnesota, about 1 in 4 women
64
Guide to Community Preventive
Services. Preventing excessive
alcohol consumption.
www.thecommunityguide.org/alcoho
l/index.html
5 A’s – Smoking Cessation
http://www.cdc.gov/tobacco/
Focus Area
Risk
Positive steps a woman can take
Examples of interventions
A woman who uses illegal or “street”
drugs during pregnancy may have a
baby who is born premature, low
birth weight, or has other health
problems such as birth defects.
Stop using street drugs prior to
pregnancy.
Develop education programs about
the risk of using illegal drugs during
pregnancy.
Taking certain medications during
pregnancy may cause serious birth
defects. The safety of many
medications taken by pregnant
women has been difficult to
determine.
Talk to a health care provider about
taking any medications. This includes
prescription and over-the-counter
medications and any dietary and
herbal products. Learn about
teratogenic drugs and other
medications affecting birth outcomes
prior to pregnancy.
(26 percent) reported smoking in the
3 months before pregnancy (MN
PRAMS data).
Illicit or “street drugs”
Teratogenic Medication
and other medications
affecting birth outcomes
Environmental Exposures
Prenatal exposures to certain
environmental factors or infections
may result in certain birth defects.
Develop referral protocol for
substance abuse treatment services.
Avoid toxic substances at work or at
home, such as synthetic chemicals,
metals, fertilizer, bug spray, and cat
or rodent feces.
Avoid exposure to certain infections
in pregnancy by getting
immunizations prior to pregnancy.
Learn how to prevent infections
during pregnancy.
65
Pharmacist Medication Therapy
Management Program – community
pharmacy or clinic based.
The American Academy of
Neurology has developed clinical
practice guidelines for women begin
treated with teratogenic medication
to guide the transition to safer
medications (American Academy of
Neurology, 2009).
Provide education for health care
providers on teratogenic medications.
Promote education on protecting
families from toxic substances and
infections.
Provide preconception rubella
immunization for women who are
non-immune.
Focus Area
Risk
Positive steps a woman can take
Examples of interventions
Nutrition and
Weight
Obesity increases the risk of several
serious birth defects including heart
defects, limb defects, diaphragmatic
hernia, anorectal atresia,
omphalocele, hypospadias.
Reach and maintain a healthy
prepregnancy BMI – reducing
obesity and overweight.
Dietician or Nutrition Educator
providing weight loss support and
healthy eating to women with a BMI
> 29.
Women capable of pregnancy should
consume 400 mcg of folic acid
DAILY (from supplements or
fortified foods) in addition to folate
from a varied diet.
Folic Acid supplement or multivitamin distribution to clinic patients
reporting not taking these on a daily
basis.
Obesity/Overweight
Maintaining and
achieving health prepregnancy BMI
Among the most common obesity
related birth defects are those related
to the brain and spinal cord.
Minnesota PRAMS data showed that
almost half of women were not at a
healthy weight before pregnancy.
Folic Acid/Folate intake
Inadequate folic acid or folate intake
– higher chance of a baby born with
anencephaly and spina bifida.
50-70% of NTD’s can be prevented
by consumption of 400 micrograms
(mcg) of synthetic folic acid per day.
Minnesota PRAMS data showed that
only about 1 in 3 women (36 percent)
delivering a live birth take a daily
multivitamin/folic acid during the
month before getting pregnant.
Chronic Disease
Diabetes
Uncontrolled diabetes can increase
risks for a variety of birth defects,
such as heart defects, NTDs, cleft lip
or cleft palate, and limb defects.
Folic acid education and distribution
program.
Other ideas can be found in the CDC
Community Guide for birth defects.
http://www.thecommunityguide.org/
birthdefects/index.html
Ensuring women with diabetes are in
good glycemic control before and
during pregnancy.
Minnesota PRAMS data showed that
about 2 percent of women have type
1 or 2 diabetes prior to pregnancy.
Diabetes case management strategies
on the basis of strong evidence of
effectiveness in improving glycemic
control (Guide to Community
Preventative Services, 2000).
Interventions that include
preconception counseling delivered
by trained professionals to achieve
optimal glycemic control.
66
Focus Area
Risk
Positive steps a woman can take
Examples of interventions
Diabetes Medication Management
example: The American Diabetes
Association has developed clinical
practice guidelines for the
preconception care of women with
diabetes (American Diabetes
Association, 2004).
Hypertension
Women who had high blood pressure
during pregnancy are at greater risk
for all types of birth defects,
particularly heart malformations and
neural tube defects.
Management of hypertension before
and during pregnancy and education
about teratogenic effects of
hypertension medications.
67
Patient education programs for
prevention and treatment of high
blood pressure and education on
stroke risk reduction.
Appendix D – Resources and References
PRECONCEPTION HEALTH
1. American College of Obstetricians and Gynecologists. Reducing Your Risk of Birth
Defects; Frequently Asked Questions 146. August 2011.
http://www.acog.org/~/media/For%20Patients/faq146.pdf?dmc=1&ts=20131120T220218
3734 Accessed 1/21/14
2. Centers for Disease Control and Prevention (CDC). Preconception Health and Health
Care website. Includes overview, information for women and men, reproductive life
plan, information for health professionals and more.
http://www.cdc.gov/preconception/index.html Accessed 1/23/14
3. Centers for Disease Control and Prevention. Preconception Health Resource Center is a
comprehensive web directory of hyperlinks to tools and resources designed to advance
the health of men and women of reproductive age. Categories available include: health
education materials for men and women, clinical strategies and model programs, policy
strategies and resources, state and local strategies and model programs. Available at
http://www.cdc.gov/preconception/freematerials-clinical.html Accessed 1/21/14
4. Centers for Disease Control and Prevention. Information for Health Professionals
including clinical content; available on CDC website at:
http://www.cdc.gov/preconception/hcp/index.html Accessed 1/23/14
5. Centers for Disease Control and Prevention. NCBDDD, CDC. (2006, April 12). Why is
Preconception Care a public health concern? Preconception, National Center on Birth
Defects and Developmental Disabilities: http://archive.is/YWiJn Accessed 12/12/13
6. Council of State and Territorial Epidemiologist Core State Preconception Health Care
Indicators http://www.cste.org/?PreconIndicators Accessed 12/12/13
7. Humphrey JR, Floyd RL. 2012. Preconception Health and Health Care Environmental
Scan. National Center on Birth Defects and Developmental Disabilities, CDC.
http://www.cdc.gov/preconception/documents/environmental-scan-report.pdf Accessed
1/21/14
8. Johnson, K., Posner, S.F., Biermann, J., Cordero, J.F., Atrash, H.K., Parker, C.S., Curtis,
M.G. (2006). Recommendations to improve preconception health and health care ---United States: A report of the CDC/ATSDR preconception care work group and the
select panel on preconception care. Morbidity and Mortality Weekly Report, 55(RR-6),
68
1-23. Available on the CDC website at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5506a1.htm Accessed 1/14/13
9. Minnesota Department of Health. Preconception Health and Health Care in Minnesota
Data book. Resource for applicants for writing grant.
http://www.health.state.mn.us/divs/fh/mch/preconception/documents/preconceptiondatab
ook.pdf Accessed 1/21/14
10. Mitchell, Elizabeth W., Verbiest, Sarah, (2013) Effective Strategies for Promoting
Preconception Health—From Research to Practice. American Journal of Health
Promotion: January/February 2013, Vol. 27, No. sp3, pp. S1-S3.
http://ajhpcontents.org/doi/full/10.4278/ajhp/27.3.c1 Accessed 1/14/14
11. Region 1 Title X Family Planning Training Center website. Resources by Topic –
Reproductive Life Planning. http://www.famplan.org/Resources/repro_life_plan.htm
Accessed 1/21/14
12. Shannon, G.D., Alberg, C., Nacul, L., & Pashayan, N. (2013). Preconception health care
and congenital disorders: Systematic review of the effectiveness of preconception care
programs in the prevention of congenital disorders. Maternal and Child Health Journal
2013 Oct 4
13. Shannon GD, Alberg C, Nacul L, Pashayan N. (2013) Preconception Healthcare
Delivery at a Population Level: Construction of Public Health Models of Preconception
Care. Matern Child Health Journal . 2013 Nov 14; . Epub 2013 Nov 14.
REPRODUCTIVE LIFE PLANS -- FOR PATIENTS
1. You're a Busy Woman: Reproductive Life Plan; Planned Parenthood Association of
Utah, University Health Care, Utah Chapter of March of Dimes, Utah Department of
Health; http://famplan.org/Resources/Docs/adult_rhp_busy_woman.pdf Accessed
1/23/14
2. You’re a Busy Teenager: Reproductive Life Plan; Utah Department of Health
Original http://health.utah.gov/mihp/pdf/RLP.pdf Access 1/22/14
3. Plan Your Health, Live Your Life; Utah Department of Health, Reproductive Health
Program (Sep 2009) Accessed 1/22/14
http://health.utah.gov/mihp/pdf/Teen_RLP_082709.pdf
4. Preconception Health and Health Care - My Reproductive Life Plan; This Reproductive
Life Plan was developed in partnership with Merry-K Moos, RN, FNP, MPH, FAAN,
69
Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill
and is based on her webinar, “Reproductive Life Plans” (February 25, 2010) Available on
the CDC website at:
http://www.cdc.gov/preconception/documents/ReproductiveLifePlan-Worksheet.pdf
Accessed 1/23/14
5. Adult and Teen Reproductive Life Plans; Adult: Set Your Mind. Set Your Goals; Teen:
My Life, My Plan; Delaware Healthy Mother and Infant Consortium
http://dethrives.com/dhmic/resources Accessed 1/22/14
6. Questions to think about Before Getting Pregnant; Group Health Incorporated (GHI)
http://famplan.org/Resources/Docs/ghi_repro_life_plan.pdf Accessed 1/21/14
7. Nurse Midwives: Planning Your Family: Developing a Reproductive Life Plan; American
College of Nurse Midwives;
http://www.midwife.org/ACNM/files/ccLibraryFiles/Filename/000000001514/Developin
g%20a%20Reproductive%20Life%20Plan.pdf Accessed 1/23/14
8. Show Your Love: Steps to a Healthier me and baby-to be; Show Your Love: Steps to a
Healthier me! (available in English and Spanish) Centers for Disease Control and
Prevention. Developed for specific groups, including women who are planning a
pregnancy, women who aren’t planning a pregnancy in the near future, couples and
women who already have a family. Available from the CDC website at:
http://www.cdc.gov/preconception/showyourlove/documents/Healthier_Baby_Me_Plan.p
df Accessed 1/22/14
REPRODUCTIVE LIFE PLANS -- FOR PROVIDERS:
1. Preconception Health and Health Care Reproductive Life Plan Tool for Health
Professionals” CDC has developed a Reproductive Life Plan (RLP) Tool for health
professionals. The RLP Tool contains questions that health professionals can use with
their patients. http://www.cdc.gov/preconception/documents/RLPHealthProviders.pdf
Accessed 1/21/14
RISK ASSESSMENT TOOLS:
Patient Administered
1. Becoming a Parent: Preconception Checklist; Wisconsin Association of Perinatal Care
website: www.perinatalweb.org and also
http://store.perinatalweb.org/index.php?route=product/category&path=62_66 Accessed
1/23/14
70
2. The Preconception Health Screening & Tune Up Form; found on the Healthy Start
website at: http://www.healthystart.info/docs/hschartcolor.pdf Accessed 1/22/14
3. Preconception screening and Counseling Checklist; March of Dimes; found on the State
of Utah website at: http://health.utah.gov/mihp/pdf/preconceptool.pdf Accessed 1/21/14
Provider Administered
1. Comprehensive Perinatal Services Program; California Department of Public Health
website: http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdph4455annotated.pdf
Accessed 1/17/14
2. Preconception Health Screening/Counseling Checklist Bernstein; Sanghvi, and Merkatz.
2000. "Improving preconception care." The Journal Of Reproductive Medicine 45, no. 7:
546-552, available from the Oregon Public Health website at:
http://public.health.oregon.gov/HealthyPeopleFamilies/Women/PreconceptionHealth/Do
cuments/counseling-checklist.pdf Accessed 1/17/14
3. Preconception Risk Assessment Tool; Illinois Department of Healthcare and Family
Services website: http://www.hfs.illinois.gov/assets/hfs27pf.pdf Accessed 1/21/14
4. Health Care Guideline Routine Prenatal Care Institute for Clinical Systems
Improvement : Appendix A: Preconception Risk Assessment Form available at
https://www.icsi.org/_asset/13n9y4/Prenatal-Interactive0712.pdf Accessed 1/21/14
NUTRITION AND WEIGHT
1. Centers for Disease Control and Prevention, United States Preventative Task Force.
Folic acid to prevent neural tube defects. The U.S. Preventive Services Task Force
(USPSTF) recommends that all women planning or capable of pregnancy take a daily
supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid. Grade: A
Recommendation (U.S. Preventative Services Task Force, 2009). Retrieved from the U.S.
Preventive Services website at:
http://www.uspreventiveservicestaskforce.org/uspstf/uspsnrfol.htm Accesses 1/21/14
2. Guide to Community Preventive Services. Atlanta: Centers for Disease Control and
Prevention (US), Office of Surveillance, Epidemiology, and Laboratory Services,
Epidemiology and Analysis Program Office, Community Guide Branch; Preventing Birth
Defects, Task Force Recommendations & Findings, Interventions to Fortify Food
Products with Folic Acid; and Preventing Birth Defects: Community-Wide Campaigns to
Promote the Use of Folic Acid Supplements Available from the Guide to Community
Preventive Services website at:
http://www.thecommunityguide.org/birthdefects/community.html Accessed 1/14/14
71
3. Centers for Disease Control and Prevention Folic Acid website. This website includes
general information about folic acid, research, articles and recommendations for
prevention including free educational materials. Accessed 1/16/14
http://www.cdc.gov/ncbddd/folicacid/index.html
4. County Health Rankings and Roadmaps: Multi-Component Obesity Prevention
Interventions website: http://www.countyhealthrankings.org/policies/multi-componentobesity-prevention-interventions Accessed 1/21/14
5. Fitch A, Everling L, Fox C, Goldberg J, Heim C, Johnson K, Kaufman T, Kennedy E,
Kestenbaun C, Lano M, Leslie D, Newell T, O’Connor P, Slusarek B, Spaniol A, Stovitz
S, Webb B. Institute for Clinical Systems Improvement. Prevention and Management of
Obesity for Adults. Updated May 2013.
https://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/
catalog_endocrine_guidelines/obesity__adults/ Accessed 1/21/14
6. Fitch A, Fox C, Bauerly K, Gross A, Heim C, Judge-Dietz J, Kaufman T, Krych E,
Kumar S, Landin D, Larson J, Leslie D, Martens N, Monaghan-Beery N, Newell T,
O’Connor P, Spaniol A, Thomas A, Webb B. Institute for Clinical Systems Improvement.
Prevention and Management of Obesity for Children and Adolescents. Published July
2013 on their website at:
https://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/
catalog_endocrine_guidelines/obesity__children/ Accessed 1/17/14
7. Rofail D, Colligs A, Abetz L, Lindemann M, Maguire L.(2012). Factors contributing to
the success of folic acid public health campaigns J Public Health (Oxf). 2012 March;
34(1): 90–99. Accessed 1/16/14 on the Journal of Public Health website at:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3285116/
8. Chiva, C; Brezis,M et.al A Systematic Review of Interventions to Increase Awareness,
Knowledge, and Folic Acid Consumption Before and During Pregnancy American
Journal of Health Promotion September/October 2007, Vol. 22, No. 1 http://hadassahmed.com/media/2013521/ASystematic.pdf Accessed 1/16/14
DIABETES
1. American Diabetes Association. (2004). Preconceptional care of women with diabetes.
Diabetes Care, 27(Suppl 1): S76-S78.
2. Guide to Community Preventive Services. (2002). Diabetes prevention and control: Case
management interventions to improve glycemic control.
http://www.thecommunityguide.org/diabetes/casemgmt.html. Accessed 1/21/14
72
TERATOGENIC MEDICATIONS
1. American Academy of Neurology has developed clinical practice guidelines for women
begin treated with teratogenic medication to guide the transition to safer medications
(American Academy of Neurology, 2009).
2. American Academy of Neurology. (2009). Practice parameter update: Management
issues for women with epilepsy – Focus on pregnancy (an evidence based review):
Teratogenesis and perinatal outcomes. Neurology, 73, 133-141. Accessed 1/22/14
http://www.guideline.gov/content.aspx?id=14680 or
http://www.neurology.org/content/73/2/142.full.html
3. Crawford, P., Appleton, R., Betts, T., Duncan, J., Guthrie, E., & Morrow, J. (1999). Best
practice guidelines for the management of women with epilepsy: The woman with
epilepsy guidelines development group. Seizure, 8, 201-17
4. Centers for Disease Control. Medications and Pregnancy web page.
http://www.cdc.gov/pregnancy/meds/ Accessed 1/23/14
ALCOHOL
1. The Centers for Disease Control and Prevention and the American College of
Obstetricians and Gynecologists (ACOG), have developed the Drinking and
Reproductive Health: A Fetal Alcohol Spectrum Disorders Prevention Tool Kit. (Centers
for Disease Control and Prevention, 2010). CDC website
http://www.cdc.gov/ncbddd/fasd/acog_toolkit.html Accessed 1/23/14
2. CHOICES: A Program for Women About Choosing Healthy Behaviors website
http://www.cdc.gov/ncbddd/fasd/documents/choices_onepager_-april2013.pdf Accessed
1/17/14
3. Centers for Disease Control and Prevention (2010). Drinking and reproductive health: A
fetal alcohol spectrum disorders prevention tool kit.
http://www.cdc.gov/ncbddd/fasd/acog_toolkit.html Accessed 1/17/14
TOBACCO
1. 5 A’s – Smoking Cessation website, http://www.cdc.gov/tobacco/ Accessed 1/16/14
2. Dartmouth Medical School (2010). Smoking Cessation for Pregnancy and Beyond is a
program, based on the “Virtual Practicum” model. It is intended for health care providers
who will be assisting their female patients in quitting smoking, in particular, patients who
are pregnant or in their child-bearing years. Dartmouth website
http://iml.dartmouth.edu/education/cme/Smoking/ or also
https://www.smokingcessationandpregnancy.org/ Accessed 1/21/14
73
3. Minnesota Department of Health. Statewide Health Improvement Program, ClinicalCommunity Linkages for Prevention Guide for Implementation FY 2014-15
http://www.health.state.mn.us/healthreform/ship/2013rfp/docs/healthcare_SHIP_3.pdf
Accessed 1/21/14
a. Additional screening and counseling tools for obesity and chronic disease
prevention and tobacco cessation website
http://www.health.state.mn.us/healthreform/ship/Implementation.html Accessed
1/21/14
FAMILY HISTORY
1. Family Health History Resources and Tools. Minnesota Department of Health website
http://www.health.state.mn.us/divs/cfh/program/cyshn/history.cfm Accessed 1/21/14
2. Facts About Birth Defects Web Page. Division of Birth Defects and Developmental
Disabilities, NCBDDD, Centers for Disease Control and Prevention.
http://www.cdc.gov/ncbddd/birthdefects/facts.html Accessed 1/21/14
HYPERTENSION
1. Minnesota Department of Health Heart Disease and Stroke Prevention program links and
resources. http://www.health.state.mn.us/divs/hpcd/chp/cvh/resources.htm Accessed
1/17/14
2. Centers for Disease Control and Prevention. High Blood Pressure website
http://www.cdc.gov/bloodpressure/ and also
http://www.cdc.gov/bloodpressure/prevention.htm Accessed 1/17/14
ENVIRONMENTAL EXPOSURES
1. Centers for Disease Control and Prevention. Tracking Network: Birth Defects and the
Environment website. http://www.cdc.gov/features/trackingnetwork/ Accessed 1/21/14
2. Centers for Disease Control and Prevention. Preconception Health and Health Care
website (5. Avoid Toxic Substances and Environmental Contaminants)
http://www.cdc.gov/preconception/planning.html Accessed 1/21/14
3. Centers for Disease Control and Prevention. Guidance for Preventing Birth Defects
website (4. Prevent infections) http://www.cdc.gov/ncbddd/birthdefects/prevention.html
Accessed 1/17/14
Other resources will be posted on the Preconception Health in Minnesota Grant Program
webpage as they become available.
74
Appendix E – PRAMS Research
Healthy People 2020: Preconception Health and Behaviors Indicators
Healthy People 2020 Preconception Indicators from MN PRAMS
Characteristics
Race
White Non-Hispanic
African American Non-Hispanic
American Indian Non-Hispanic
Other Non-Hispanic
Hispanic
Age Group (yrs)
<20
20-34
>=35
Pregnancy Intention
Intended
Unintended
Prepregnancy Insurance Status
Private
Medicaid
None
Urban/Rural
Twin Cities Metro (7 county metro region)
Greater MN
MN Baseline (2007-2008)
Healthy People 2020 Baseline (2007)
Healthy People 2020 Target
Take multivitamins/folic acid prior
to pregnancy*
No smoking prior to
pregnancy**
No alcohol use prior to
pregnancy
Healthy weight prior to
pregnancy#
Percent
95% CI
Percent
95% CI
Percent
95% CI
Percent
95% CI
37.8%
23.2% ^
12.9% ^
31.5%
20.2% ^
(35.6-40.1)
(18.4-28.8)
(9.5-17.5)
(24.0-40.1)
(15.3-26.3)
74.2%
80.1%
37.7% ^
87.4%
93.0%
(72.1-76.2)
(76.3-83.4)
(29.9-46.1)
(80.0-92.4)
(88.8-95.6)
25.3% ^
61.7%
35.4%
68.7%
78.9%
(23.3-27.4)
(55.8-67.2)
(28.0-43.7)
(60.1-76.3)
(72.8-84.0)
52.9%
45.2%
41.5%
68.0%
51.6%
(50.6-55.2)
(39.0-51.5)
(32.2-51.5)
(59.0-75.9)
(43.4-59.7)
18.2% ^
33.9%
44.6%
(13.1-24.6)
(31.8-36.0)
(39.5-49.8)
69.3%
75.0%
89.3%
(61.9-75.8)
(73.0-76.8)
(85.6-92.2)
66.4%
33.6%
34.4%
(58.7-73.2)
(31.5-35.7)
(29.6-39.5)
64.3%
51.7%
55.0%
(56.6-71.3)
(49.4-53.9)
(49.7-60.2)
44.3%
17.5% ^
(41.9-46.7)
(15.1-20.1)
83.3%
64.9% ^
(81.4-85.1)
(61.6-68.0)
35.9%
35.3%
(33.5-38.4)
(32.2-38.5)
54.0%
51.0%
(51.5-56.5)
(47.7-54.4)
42.5%
23.6% ^
14.5% ^
(40.2-44.9)
(19.6-28.2)
(11.5-18.1)
82.8%
59.7% ^
67.7% ^
(80.9-84.5)
(54.6-64.6)
(63.3-71.9)
28.2% ^
50.4%
51.3%
(26.1-30.4)
(45.2-55.5)
(46.6-55.9)
54.5%
44.6% ^
54.0%
(52.1-56.9)
(39.5-49.8)
(49.1-58.9)
36.5%
31.4%
(34.0-39.0)
(28.7-34.2)
81.0%
70.7% ^
(78.9-82.9)
(67.8-73.4)
38.9%
31.9%
(36.4-41.5)
(29.1-34.8)
56.2%
49.0%
(53.5-58.8)
(45.9-52.0)
76.6%
77.6%
85.4%
(74.9-78.2)
35.9%
51.3%
56.4%
(34.0-37.8)
53.0%
48.5%
53.4%
(51.0-55.0)
(32.5-36.2)
34.2%
30.1%
33.1%
* every day in month prior to
pregnancy
** 3 months prior to pregnancy
#
BMI 18.5-24.9
^ = Statistically below MN 2007-2008 Baseline
Barber, C., Harvey, J., & Punyko, J. (2011, September 19). Preconception Health Measures of Minnesota Women: An Analysis of Minnesota Pregnancy Risk
Assessment Monitoring System (PRAMS) 2007-2008. The Deborah E. Powell Center for Women’s Health 8th Annual Women’s Health Research Conference
75