Attachment 8_General Applicant Information NOFO.docx

Attachment 8. General Applicant Information

Applicants must provide responses to the required information below.

Statutory Eligibility Requirement: Mission Statement and Multiple Drugs of Misuse

1. Please insert the coalition’s Mission Statement on the right. As noted in Table 4: Statutory Eligibility Requirements, the coalition must have as its principal mission the reduction of youth substance use

2. Please list the substances targeted by the coalition. The coalition must have developed a 12-Month Action Plan to reduce substance use among youth which targets multiple drugs of misuse.

Substances may include, but are not limited to, narcotics, depressants, stimulants, hallucinogens, inhalants, marijuana, alcohol, and tobacco, where youth use is prohibited by federal, state, or local law. (21 USC 1531 §1032 (a)(4)(D)). Use this attachment to upload a list of the coalition's targeted drugs of abuse.

Coalition and Community Information

3. Geographical boundaries served by the coalition (e.g., city, county, streets, township, pueblo, reservations, villages, etc.)

4. List all zip codes served by the coalition. Go to: https://tools.usps.com/go/ZipLookupAction!input.action

5. What is the population size of the community served by the coalition?

6. What is the median income in your area or county?

7. Does the coalition serve a federally recognized tribal area? Indicate Yes or No. If yes, applicant must provide the name of tribe.

8. Does the coalition serve tribal members? Indicate Yes or No.

9. Does the coalition have representation that includes at least one representative of the Bureau of Indian Affairs, the Indian Health Service, or a tribal government agency with expertise in the field of substance abuse? Indicate Yes or No. If yes, applicant must identify the representative’s name and organizational entity.

10. Provide the date you registered in the SAM.

NOTE: Failure to have an active registration will make your application ineligible.

11. What is the racial/ethnic demographic make-up of the community being served by the coalition? Please provide percentages, which are available from the US Census.

US Census data can be found at the following resource: data at https://www.census.gov/acs/www/data/data-tables-and-tools/data-profiles/

12. When was the substance use prevention coalition created? Provide month, day, and year.

See Section H. Other Information of the NOFO (FOA CDC-RFA-CE21-2107) for instructions to upload this attachment.