The code block below illustrates how one might use # and // as comments in your logic and calculations.

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EHDI Grant Review Process Participant Application

The Center for Health Equity is seeking volunteers to participate in the Eliminitating Health Disparities Initiative (EHDI) grant review process, which will take place in January-March 2023. The community review process will support MDH in selecting the best applications for funding in response to the EHDI Request for Proposals, which was released on October 3, 2022. If interested please fill out the below application.

Full Name:

* must provide value

Occupation:

* must provide value

Organization:

* must provide value

Email:

* must provide value

Phone:

* must provide value

Address:

* must provide value

City:

* must provide value

State:

* must provide value

Zip Code:

* must provide value

County of Residence:

* must provide value

Do you have lived experience and/or expertise in any of the following areas?

* must provide value

Breast and cervical cancer

Cardiovascular disease

Diabetes

HIV/AIDS and STIs

Immunizations for adults and children

Infant mortality and prenatal care

Teen pregnancy prevention

Unintentional injuries and violence

Health equity

Social determinants of health/root causes

Policy, systems and environmental change

Participating in an EHDI or similar community-based program

Other

If other, please explain:

Do you have experience administering and/or reviewing state, federal, foundation or community grants?

* must provide value

Yes

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If yes, check all that apply:

* must provide value

State Agency Grants (e.g., EHDI, Family Planning, HIV/AIDS, Tobacco, etc.)

Foundations Grants (e.g., United Way, Blue Cross and Blue Shield of MN, Minneapolis Foundation)

Local Grants (City or county public health or other department grants)

Federal Grants

Other

Please briefly describe any experience you have in reviewing/facilitating/note taking grant applications (100 words max).

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Please indicate your preferred role(s):

* must provide value

Reviewer

Facilitator

Note taker

Please describe why you are interested in being a reviewer/facilitator/note taker. (100 words max)

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All review process participants must attend one group review team meetings. The review team meetings will take place virtually on the following dates/times. Please indicate your availability.

* must provide value

Group 1 review meetings: Monday, February 27 (9:00 am-12:00 pm) and Tuesday, February 28 (9:00am - 12pm)

Group 2 review meetings: Wednesday, March 1 (9:00 am-12:00 pm) and Thursday March 2 (9:00am - 12:00PM)

To the best of your knowledge, do you have a conflict of interest with an organization that is applying for an EHDI grant?

A conflict of interest exists related to an application you are assigned to review when:
(1) you have been involved in the submission/development of the grant application,
(2) you are employed by the applicant agency(ies),
(3) you are involved in the governance of the applicant agency(ies), e.g., on a board of directors,
(4) current or historical circumstances exist that would hinder your ability to objectively rate a proposal, e.g. if you are a former employer, volunteer, coalition member, advisory member, etc.

* must provide value

Yes

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If you selected yes for conflict of interest, please list the name of the agency or agencies:

* must provide value

If you are selected as participant, MDH will provide more detailed information regarding our conflict of interest policy and require all participants to sign a Conflict of Interest Disclosure Form.

How would you describe your race or ethnicity?

How would you describe your sexual orientation?

How would you describe your gender identity?

Do you have a disability?

Yes

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If yes, please indicate the type of disability and whether you'll need accommodations (e.g, ASL interpreter).

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.