1.	Organization Name:
2.	Organization Type:
3.	Organization Website:
		(e.g., www.minorityinitiatives.com)
4.	Project/Initiative Title:

5.	Project/Initiative Contact Information:
	Name: Title: Address: City: State: Zip: Phone: Fax: Email: (e.g., 123-456-7890) (e.g., 123-456-7890) (e.g., jdoe@example.com)
6.	Health Disparity Area:
	Cardiovascular Disease HIV/AIDS Cancer Diabetes	Immunization Adult Immunization Child Infant Mortality Other Explain:
7.	Racial/Ethnic Groups (Check all that apply):
	Black/African-American Hispanic/Latinos American Indian/Alaska Native Asian American Native Hawiian/Other Pacific Islander Other Explain: All Races
8.	Age Groups (Check all that apply):
	Infants & Toddlers (0-3 yrs) Child/Youth (4-12 yrs) Teens (13-18 yrs) Young Adults (19-25 yrs)	Adults (26-54 yrs) Senior (55-64 yrs) Elderly (65+ yrs) All Ages
9.	Gender: Male Female Male and Female
10.	Specific Populations (Check all that apply):
	Families Homeless Low Income Low Literate Migrant Workers	Underinsured Uninsured Other Explain: All Populations
11.	Services Provided (Check all that apply):
	Transportation Screening/Treatment/Follow-Up Treatment Only Screening Only Minority Health Professions Development Enhance/Facilitate Private/Public Partnerships Ensure Adequate Infrastructure/Resources Increase Health Literacy	Outreach Training Create Educational Materials Grant Writing Insurance Coverage Research/Clinical Trials Data Collection Assessment/Evaluation Education/Outreach (Presentations, Etc.) Public Relations (Media) Behavior Modification Other Explain:
12.	Duration: Less than 1 Year 2-5 Years 6-10 Years Other Explain:
13.	Project/Initiative Scheduled to End: 2005 2006 2007 2008 2009 2010 Other Explain:
14.	Setting (Check all that apply):
	Community Health Department Worksite Hospital Church Faith Store/Mall Restaurant	Communitiy Health Center Grocery Store Daycare Facility Doctor's Office School/College Recreational Facility Other Explain:
15.	Project/Initiative Conducted In: Rural Area Urban Area Both
16.	Select Primary County(s) of Project/Initiative To Multi-Select, hold down the CTRL key and click on desired counties.	All Counties in South Carolina Abbeville Aiken Allendale Anderson Bamberg Barnwell Beaufort Berkeley Calhoun Charleston Cherokee Chester Chesterfield Clarendon Colleton Darlington Dillon Dorchester Edgefield Fairfield Florence Georgetown Greenville Greenwood Hampton Horry Jasper Kershaw Lancaster Laurens Lee Lexington McCormick Marion Marlboro Newberry Oconee Orangeburg Pickens"> Richland Saluda Spartanburg Sumter Union Williamsburg York
17.	Please provide a brief description of your Project/Initiative as it would appear on the Office of Minority Health's webpage (50 words or less):
18.	Has the Project/Initiative Been Formally Evaluated? Yes No
	If Yes, The Outcomes Resulted In... Policy Change Environmental Change Increased number of persons impacted Increased knowledge base Increased fiscal resources Changed attitudes and behavior Other Explain:
19.	Please explain why your Project/Initiative is a *best/promising practice. (30 words or less): * Best/promising practices have four common characteristics: a) they are innovative, b) They make a difference, c) they have a sustainable effect, and d) they have the potential to be replicated and to serve as a model for generating initiatives elsewhere.
20.	Prevention Level (Check all that apply): Primary (Targets persons who are at low risk or not currently affected by certain illness) Secondary (Targets persons with major risk factors) Tertiary (Targets persons with the illness or disease, provides medical treatment and referral)
21.	Challenge(s) to Your Efforts (Check all that apply):
	Recruitment/Retention of Participants Recruitment/Retention of Providers Establishing Partnerships Implementation Process Transportation	Fiscal Resources Treatment Options Screening Services Data Collection Medicaid/Medicare Reimbursements Other Explain:
22.	Funding Agency(s): Centers for Disease Control and Prevention (CDC) National Institutes of Health (NIH) US Department of Health and Human Services (HHS) US Office of Minority Health SC DHEC Susan G Koman Foundation American Cancer Society Robert Wood Johnson California Endowment Foundation Other Explain:
23.	Funding Source (Check all that apply): Private Donor Foundation Federal Government State Government Local Government Corporate Other Explain:
24.	Funding Level: $
25.	Is the Project/Initiative Being Implemented by Other Entities? Yes No
	If Yes (Identify):
26.	Project/Initiative Partners:
27.	List contact information for other minority health disparity project/initiatives you are aware of:
Survey Completed By:
	Name: Title: Address: City: County: State: Zip: Phone: Fax: Email: (e.g., 123-456-7890) (e.g., 123-456-7890) (e.g., jdoe@example.com)
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