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2013 Model Practices (Public)Application Name: 2013 Model Practices (Public) : Tri-County Health Department : A new dimension to measuring changes in access to healthy food in school lunches Applicant Name: Dr. Allison Hawkes Application Title: A new dimension to measuring changes in access to healthy food in school lunches Please enter email addresses you would like your confirmation to be sent to. sweinberg@tchd.org Practice Title A new dimension to measuring changes in access to healthy food in school lunches Submitting LHD/Agency/Organization Tri-County Health Department Head of LHD/Agency/Organization Richard L. Vogt, MD Street Address 6162 S Willow Dr, Suite 100 Practice Contact Person Stacy Weinberg, MA Title Director, Epidemiology, Planning and Communication Submitting LHD/Agency/Organization Web Address (if applicable) www.tchd.org Provide a brief summary of the practice in this section. This overview will be used to introduce the model or promising practice in the Model Practices Database. Although this section is not judged, the judges use it to get an overall idea about your practice. You must include answers to the following questions in your response:
• Size of population in your health department’s jurisdiction
• Who is your target population/audience, what is the size of your intended population/audience for this practice and what percent of your target population did you reach?
•Provide the demographics of your target population (i.e. age, gender, race/ethnicity, socio-economic status)
• Describe the nature and gravity of the public health issue addressed
• List the goal’s and objective(s) of the practice and clearly link them to the problem or issue the practice is addressing.
• Describe the potential public health impact of the practice, and the likely effectiveness of the practice being implemented as intended, and the ease of adoption of the practice by other LHDs.
In your description, also address the following
• When (month and year) the practice was implemented.
• Briefly describe how the practice was implemented, what were major activities, and any start-up and in-kind costs and funding services.
• Outcomes of practice (list process milestones and intended/actual outcomes and impacts.
• Were all of the objectives met?
• What specific factors led to the success of this practice? Tri-County Health Department (TCHD) is the largest local public health agency in the State of Colorado, serving approximately 1.3 million residents in Adams, Arapahoe, and Douglas Counties. There are 15 school districts across the three-county region. The target population for this practice is the more than 250,000 children and youth attending school in one of the 15 school districts.
The population is diverse, and varies according to county. According to the 2010 census, approximately 16% of TCHD’s population is young children 9 years of age or younger; 14% are teens 10 to 19 years of age. The jurisdiction has a large Hispanic population (22.7%); and 5.5% of the residents are Black/African-American; 4.3%, Asian or Pacific Islander; and 2.6%, other races. The remaining residents are White (64.7%). The 15 school districts are varied in their percentages of students eligible for free and reduced lunch from less than 1% to 96.4%.
This practice addresses childhood obesity. Close to nineteen percent (18.6%) of adolescents reported a BMI in the overweight or obese range on the 2010 Youth Risk Behavior Survey conducted in the TCHD jurisdiction as part of our Communities Putting Prevention to Work grant. And the 2010 Colorado Child Health Survey revealed that 22.9% of Colorado children between the ages of 1 and 14 years were overweight or obese. A 2007 study revealed that Colorado had the second fastest growing rate of childhood obesity in the nation, second only to Nevada.
Between June 2009-June 2012, during our Communities Putting Prevention to Work grant, we worked with the 15 school districts in our jurisdiction on their efforts to influence healthy eating habits. During this work, our school districts looked to us to help them evaluate and measure the changes they were making to their school lunches. We recognized the need for a tool that local public health agencies could use in working with their school partners in this area.
Overall goal of our practice was measure changes in access to “more healthy” and "less healthy” foods in school cafeteria lunches.
Objectives:
1. Create a tool to evaluate and quantify, in a relatively simple way, changes in access to “more healthy” and “less healthy” foods in school cafeteria lunches (excluding a la carte).
2. Identify applications of this tool that would articulate the changes in access from several perspectives.
3. Implement this tool across the 15 school districts in the TCHD jurisdiction and communicate the changes to our funder and back to the school districts for their use.
TCHD registered dietitians consulted with food service directors from each district to learn how food items were prepared, and developed set criteria to rate food items as “more healthy” or “less healthy.” One dietitian coded 20 consecutive days of school cafeteria “production sheets” obtained from one representative elementary and middle school in each district. For each food item, the following were recorded: type (entrée, fruit, vegetable, grain) “healthy” rating (i.e., “more healthy” or “less healthy”), and number of planned servings. Ratios of “more healthy” to “less healthy” planned servings of food items were calculated for both “pre” and “post” years (2009 and 2011). Data were analyzed across the TCHD jurisdiction.
All of the objectives were met; results disseminated to CDC and our school districts.
Overflow: Please finish the response to the question above by using this text area. Please be mindful of the word limits. The number of planned servings of “more healthy” food items increased by 17.4%; “less healthy” food items decreased by 34.3%. Ratio of “more healthy” to “less healthy” planned servings increased from 2.08(2009) to 3.71(2011).
Factors important to the success of this practice:
• Building relationships with the food service directors and superintendents in all school districts.
• Using one staff member to code the production sheet content helped ensure quality control and consistency of coding.
Measuring and quantifying improvements in access to healthier foods in school cafeterias will be instrumental in demonstrating intermediate outcomes along the path to the longer term outcome of reducing childhood obesity. Until now, most of this measurement has focused on the increases in the number of more healthy food items and decreases in the number of less healthy food items on school lunch menus/lunch lines. Our practice looks deeper at the planned servings of each of the food items, and teases out a more accurate measure of access. The challenging part of this practice was developing the coding tool; now that the tool has been developed and piloted, it will not be difficult for other LHDs to use it in their work with school districts.
You may provide no more than two supplement materials to support your application. These may include but are not limited to graphs, images, photos, newspaper articles, etc. Describe the public health issue that this practice addresses. (350 word limit) The public health issue this practice addresses is childhood obesity. Close to nineteen percent (18.6%) of adolescents reported a BMI in the overweight or obese range on the 2010 Youth Risk Behavior Survey conducted in the TCHD jurisdiction as part of our Communities Putting Prevention to Work grant(CPPW). And the 2010 Colorado Child Health Survey revealed that 22.9% of Colorado children between the ages of 1 and 14 years were overweight or obese. A 2007 study revealed that Colorado had the second fastest growing rate of childhood obesity in the nation, second only to Nevada. This is a critical situation because we know that health risk behaviors are established in childhood and adolescence and we are already seeing chronic disease health risks becoming more and more common among young people.
Between June 2009-June 2012, during our CPPW grant, we worked with the 15 school districts in our jurisdiction in their efforts to influence healthy eating habits. During this work, our school districts looked to us to help them evaluate and measure the changes they were making to their food offerings. We recognized the need for a tool that local public health agencies could use in working with their school partners in this area. In examining the tools that existed, we found that they generally focused on measuring increases in the numbers of more healthy food items on the school lunch menu/lunch-line, and/or decreases in the numbers of less healthy food items. We wanted to take this analysis to a deeper level because we realized that simply examining the number of healthier food items on the menus/lunch-line could be misleading – unless one looks at the number of planned servings of the food items. For example, if a district adds two healthy items per meal, but plans on serving fewer servings of the more healthy items and more servings of the less healthy items, they haven’t increased access to healthier foods as much as it might seem on the face of it. Our approach allows for this more detailed examination of the actual access afforded to students.
What process was used to determine the relevancy of the public health issue to the community? (350 word limit) We used several methods to determine the relevancy of this public health issue to our community. First, we examined relevant data, including the data sources discussed above. Next, we gathered the superintendents of the 15 school districts in our jurisdiction and asked them to help us identify and prioritize the best approaches to address this issue. We engaged two of the superintendents on our Leadership Team who were particularly passionate about the role of schools in helping to address childhood obesity; these two advocates were key to the engagement of the other superintendents. We also met with each of the food service directors from the school districts and gleaned valuable insight into their experience and observations of the students in their schools. In addition, they spoke with us at length about the new nutrition guidelines for schools and their plans for implementing them. How does the practice address the issue? (350 word limit) This practice provides LHDs with a tool that they can use to create partnerships with the leadership of the school districts in their jurisdiction. LHDs are uniquely positioned to offer assessment and evaluation skills and tools to their partners, who might not have access to such resources. With this tool, a LHD can help school districts document the changes in their school lunch offerings, which is valuable data that can be used by the school district to communicate with students, parents and Boards of Education. In addition, LHDs can demonstrate to school districts how the data collected with this tool can be useful in pursuing grant funding to support their healthier eating initiatives.
This practice addresses the CDC Winnable Battle of Nutrition, Physical Activity and Obesity. Nutrition, Phyiscal Activity and Obesity Please list any evidence based strategies used in developing this practice. (Provide links or other materials for support) In developing this practice, we drew from:
• Institute of Medicine’s guidelines in School Meals: Building Blocks for Healthy Children, Oct 2009
• Institute of Medicine’s guidelines in Nutrition Standards for Foods in Schools April 2007
• USDA Healthier US Schools Challenge
• GO-SLOW-WHOA Criteria from Texas CATCH, We Can! Program and as adapted by Aurora Public Schools with Livewell Colorado
• Proposed USDA School Lunch regulations Jan 2011
• Dietary Guidelines for Americans, 2010, USDA-HHS
• Colorado Department of Education’s Training booklet Creating Healthy Cycle Menus June 2011 Is the practice new to the field of public health? If so, answer the following questions. Yes What process was used to determine that the practice is new to the field of public health? Please provide any supporting evidence you may have, e.g. literature review. We conducted a literature review to determine how others measured the effect of school food policy changes on access to healthier foods. Included below is a partial list of the peer-reviewed publications that we read. • Cullen KW, Hartstein J, Reynolds KD, et al. Improving the school food environment: Results from a pilot study in middle schools. J Am Diet Assoc. 2007;107(3):484-489.
• Cullen KW and Watson KB. The impact of the Texas Public School Nutrition Policy on student food selection and sales in Texas. American Journal of Public Health. 2009;99(4):706-712.
• Lytle LA, Kubik MY, Perry C. Influencing healthful food choices in school and home environments: results from the TEENS study. Prev Med. 2006 Jul;43(1):8-13.
• Condon EM, Crepinsek MK, Fox MK. School meals: Types of food offered to and consumed by children at lunch and breakfast. J Am Diet Assoc. 2009;109:S67-S78.
• Bartholomew JB, Jowers EM. Increasing frequency of lower-fat entrees offered at school lunch: An environmental change strategy to increase healthful selections. J Am Diet Assoc. 2006;106:248-252.
• Michaels KB, Bloom BR, Riccard P, et al. A study of the importance of education and cost incentives on individual food choices at the Harvard School of Public Health Cafeteria. Journal of the American College of Nutrition. 2008;27(1):6-11.
How does this practice differ from other approaches used to address the public health issue? Others have measured the effect of school food policy changes on access to specific healthier foods (such as lower fat items, fruits and/or vegetables) in school lunch menus/lunch lines, however, none of the studies we reviewed included changes to all types of food, i.e., entrees, fruits, vegetables, and grains.
Is the practice a creative use of an existing tool or practice? If so, answer the following questions. No What process was used to determine that the practice is a creative use of an existing tool or practice? Please provide any supporting evidence you may have, for example, literature review. What tool or practice (e.g., APC development tool, The Guide to Community Preventive Services, HP 2020, MAPP, PACE EH, etc.); did you use in a creative way to create your practice? (if applicable) (300 word limit total)
a. Is it in NACCHO’s Toolbox; (if not, have you uploaded it in the Toolbox)?
b. If you used a tool or practice to implement your practice, how was your approach to implementing the tool unique and innovative for your target area/population? How does this practice differ from other approaches used to address the public health issue? This practice is similar to a component of the “Smart Choices: Creating a Healthy School Environment” model practice submitted by the Dakota County Public Health Department of Minnesota in 2011. Our practice differs in that in the Dakota County Model Practice, they focus on measuring the number of more healthy food items offered as part of the school breakfast and lunch programs. Our practice looks deeper at the planned servings of all items as part of the school lunch program. For example, if a district adds two healthy items per meal, but plans on serving fewer servings of the healthier items than the less healthy items, they haven’t really increased access to healthier foods overall. Our approach allows for this more detailed examination of the actual access afforded to students. Who were the primary stakeholders in the practice? The primary stakeholder organizations in our practice were the 15 school districts in the TCHD jurisdiction overall. Specifically, the food service directors and superintendents of each district, as well as the wellness coordinators were the key representatives from their stakeholder organizations.
What is the LHD's role in this practice? TCHD’s role in this practice was three-fold. First, we convened all of the stakeholders on multiple occasions to gather input for the development of the tool. Second, TCHD staff developed the coding tool and the database to enter the data from the production sheets. Finally, TCHD staff input and analyzed the data and disseminated it back out to the school districts. What is the role of stakeholders/partners in the planning and implementation of the practice? Each school district provided input to the tool development through various representatives including their CPPW District Wellness Coordinator, their Food Service Director and their Superintendent. The District Wellness Coordinators met twice a month over the course of the grant to provide input to the work and serve as the liaison back to the school district to ensure follow-through on all grant-related activities.
What does the LHD do to foster collaboration with community shareholders?
Describe the relationship(s) and how it furthers the practice's goals. TCHD staff had worked with our 15 school districts over many years and had developed good relationships with many of the stakeholders we engaged in this practice. We have a dietitian on staff in our Nutrition Division who serves on the wellness committees of several of our districts and serves as a resource to others. In addition, we work with the School District health staff on a regular basis addressing cases of communicable disease that require public health intervention. In 2009, when the H1N1 epidemic occurred, we partnered with our 15 school districts to hold community vaccination clinics in over 40 schools, providing more than 60,000 H1H1 vaccinations to the community. This experience established a strong foundation from which to form the partnerships needed for our school nutrition initiative. Despite the end of our CPPW grant, these relationships continue to grow stronger. In 2012, we will be starting a tobacco control policy initiative in partnership with all 15 school districts, which will integrate nicely with our chronic disease prevention efforts.
Describe lessons learned and barriers to developing collaborations. We learned several valuable lessons in developing our healthy school meals collaboration, and specifically the development and implementation of the access to healthy foods evaluation tool. First, it was critical to involve the school district food service staff right from the beginning. We recognized that it would not be practical to ask them to collect additional data for this evaluation, so we asked them to show us what data they currently collect and then we conceptualized the tool based on those data sources – namely the food service production sheets. Second, it was helpful for us to take the time to discuss with the districts the ways in which they could benefit from the data that would result from this evaluation (e.g., new funding opportunities, reporting to school boards and parent advisory committees, engaging students to make further changes). The primary barrier was some initial skepticism from the food service directors as to our agenda; once they understood our purpose and how it could benefit them, they engaged fully. Evaluation assesses the value of the practice and the potential worth it has to other LHDs and the populations they serve. It is also an effective means to assess the credibility of the practice. Evaluation helps public health practice maintain standards and improves practice.
Two types of evaluation are process and outcome. Process evaluation assesses the effectiveness of the steps taken to achieve the desired practice outcomes. Outcome evaluation summarizes the results of the practice efforts. Results may be long-term, such as an improvement in health status, or short-term, such as an improvement in knowledge/awareness, a policy change, an increase in numbers reached, etc. Results may be quantitative (empirical data such as percentages or numerical counts) and/or qualitative (e.g., focus group results, in-depth interviews, or anecdotal evidence).
List up to three primary objectives for the practice. For each objective, provide the following information: (750 word limit per objective)
• Performance measures used to evaluate the practice: List the performance measures used in your evaluation. Depending on the type of evaluation conducted, these might be measures of processes (e.g., number of meetings held, number of partners contacted), program outputs (e.g., number of clients served, number of informational flyers distributed), or program outcomes (e.g., policy change, change in knowledge or attitude, change in a health indicator)
• Data: List secondary and primary data sources used for the evaluation. Describe what primary data, if any were collected for each performance measure, who collected them, and how.
• Evaluation results: Summarize what the LHD learned from the process and/or outcome evaluation. To what extent did the LHD successfully implement the activities that supported that objective? To what extent was the objective achieved?
• Feedback: List who received the evaluation results, what lessons were learned, and what modifications, if any, were made to the practice as a result of the data findings.
Objective 1: Create a tool to evaluate and quantify, in a relatively simple way, changes in access to “more healthy” and “less healthy” foods in school cafeteria lunches (excluding a la carte).
Objective 2: Identify applications of this tool that would articulate the changes in access from several perspectives.
Objective 3: Implement this tool across the 15 school districts in the TCHD jurisdiction and communicate the changes to our funder and back to the school districts for their use.
Objectives 1 and 2 were essentially process objectives leading to the implementation of the tool in Objective 3, so we will present a single evaluation discussion that encompasses all three of them.
• Performance measures used to evaluate the practice: List the performance measures used in your evaluation. Depending on the type of evaluation conducted, these might be measures of processes (e.g., number of meetings held, number of partners contacted), program outputs (e.g., number of clients served, number of informational flyers distributed), or program outcomes (e.g., policy change, change in knowledge or attitude, change in a health indicator)
• Data: List secondary and primary data sources used for the evaluation. Describe what primary data, if any were collected for each performance measure, who collected them, and how.
• Evaluation results: Summarize what the LHD learned from the process and/or outcome evaluation. To what extent did the LHD successfully implement the activities that supported that objective? To what extent was the objective achieved?
• Feedback: List who received the evaluation results, what lessons were learned, and what modifications, if any, were made to the practice as a result of the data findings.
The performance measures employed included: successfully meeting with the food service directors of each of our 15 school districts (some multiple times) to gather input on data sources and determining how food items were prepared in their district; development of an analysis plan that detailed the various ways we would look at the production sheet data and the various messages that could be delivered via each rubric; and the final measure, which was the actual measurement of change in access to “more healthy” and “less healthy” foods in school lunches.
The main data source for this evaluation was primary data that was already being collected by the school district food service staff on their daily production sheets.
The results of the evaluation were very exciting. In terms of process, this proved to be a very effective tool for gaining greater insight into access to healthier foods in school lunches by examining “planned servings” of food items rather than just the number of food items themselves. In several instances, a school district had added several healthier food items to their menu and removed “less healthy” items, but only planned for a small number of servings of the healthier items and a larger number of servings of the “less healthy items.”
The outcomes of the actual evaluation analysis were striking.
First we analyzed the data across all food groups (entrees, fruits, vegetables, and grains). In 2009, there were 397,685 planned servings of “more healthy” food items, and 191,565 servings of “less healthy” food items for a ratio for “more healthy” to “less healthy” planned servings of 2.08. In 2011, the number of planned servings of “more healthy” food items was 466,842 and “less healthy,” 125,879 for a ratio of 3.71. These results were statistically significant ( X2= 19,110, 1 d.f., p<0.001). Another way of stating these findings is that the number of planned servings of “more healthy” food items increased by 17.4% and the planned servings of “less healthy” food items decreased by 34.3%.
To get a better idea of how these results were achieved, we determined the changes in the types of specific food items.
Overflow (Objective 1): Please finish the response to the question above by using this text area. Please be mindful of the word limits. From 2009-2011, the planned servings of some of the “less healthy” food items such as french fries decreased from 51,000 to 23,000, hot dogs from 11,000 to 6,000, and breaded chicken from 13,000 to 6,000; for the “more healthy” food items, plain chicken increased from 4,500 planned servings to 11,000; plain beef, pork, or roast beef from 2,890 to 6,116, and fresh fruit from 50,324 to 81,575 planned servings.
Next, we examined the results for entrées. In 2009, the planned servings of “more healthy” entrees equaled 86,211, and “less healthy,” 109,658. The resulting ratio was 0.79. In 2011, the ratio increased to 1.23; there were 110,560 planned servings of “more healthy” entrees and 89,747 planned servings of “less healthy.”
Finally, we assessed the changes by district, and again, the results were illuminating. The largest overall change in all food groups from 2009-2011 was observed in one district that made dramatic changes to its menu: the ratio increased from 1.70 to 21.3. Another district went from a ratio of less than 1 (meaning that the planned servings of “less healthy” food items outnumbered those of “more healthy”), to 1.68. A decrease was noted for one district – the ratio in 2009 was 5.12 (the highest of any district) and in 2011, it was 3.81. Most districts had results in the range of those observed for the entire jurisdiction.
The evaluation results will be distributed to the Superintendents and Food Service Directors of our 15 school districts. The results were also shared with our CPPW Leadership Team, our Board of Health, and were presented at the statewide Public Health in the Rockies conference. One lesson we learned was that it was helpful to have one person code the production sheet data. This maintained consistency. Another lesson learned was that different school districts use different labels for the columns on their production sheets (i.e., “planned servings” are not always labeled as such) so it is critical to make sure that you are using the correct data when entering for analysis. Using a ratio to compare results from year to year or across schools, districts, etc. is advantageous because it is unaffected by changes in school enrollment or by the number of students purchasing school meals.
Overflow (Objective 2): Please finish the response to the question above by using this text area. Please be mindful of the word limits. Overflow (Objective 3): Please finish the response to the question above by using this text area. Please be mindful of the word limits. What are the specific tasks taken that achieve each goal and objective of the practice? Major implementation activities:
• TCHD registered dietitians consulted with food service and nutrition directors from each district to learn how food items were prepared in each district
• TCHD registered dietitians developed set criteria to rate food items as “more healthy” or “less healthy”
• Twenty consecutive days of school cafeteria “production sheets” were obtained from one representative elementary and middle school in each district; production sheets track what food items were offered on the school lunch menus and how many servings of each food item were planned and prepared. “Pre” data were collected from 2009 and “post” data were collected in 2011.
• For each food item, the following were recorded: type (entrée, fruit, vegetable, grain) “healthy” rating (i.e., “more healthy” or “less healthy”), and number of planned servings
• Ratios of “more healthy” to “less healthy” planned servings of food items were calculated for both “pre” and “post” years (2009 and 2011).
• Data were analyzed across the TCHD jurisdiction and shared with individual school districts as well.
What was the timeframe for carrying out these tasks? The development of the tool for categorizing the food items as “more healthy” and “less healthy” was accomplished over a six month period from December 2010-May 2011. The actual process of gathering the production sheets, entering and analyzing the pre and post data took place over a nine-month period, as the data were made available, from October 2011-June 2012.
Please provide a succinct outline of some basic steps taken in implementing your practice. Major implementation activities:
• TCHD registered dietitians consulted with food service and nutrition directors from each district to learn how food items were prepared in each district
• TCHD registered dietitians developed set criteria to rate food items as “more healthy” or “less healthy”
• Twenty consecutive days of school cafeteria “production sheets” were obtained from one representative elementary and middle school in each district; production sheets track what food items were offered on the school lunch menus and how many servings of each food item were planned and prepared. “Pre” data were collected from 2009 and “post” data were collected in 2011.
• For each food item, the following were recorded: type (entrée, fruit, vegetable, grain) “healthy” rating (i.e., “more healthy” or “less healthy”), and number of planned servings
• Ratios of “more healthy” to “less healthy” planned servings of food items were calculated for both “pre” and “post” years (2009 and 2011).
• Data were analyzed across the TCHD jurisdiction and shared with individual school districts as well.
What were some lessons learned as a part of your program's implementation process? One lesson we learned was that it was helpful to have one person code the production sheet data. This maintained consistency. Another lesson learned was that different school districts use different labels for the columns on their production sheets (i.e., “planned servings” are not always labeled as such) so it is critical to make sure that you are using the correct data when entering for analysis. Using a ratio to compare results from year to year or across schools, districts, etc. is advantageous because it is unaffected by changes in school enrollment or by the number of students purchasing school meals. Provide a breakdown of the overall cost of implementation, including start-up and in-kind costs and funding services. The costs of implementation were largely staff time, which was funded by our CPPW grant. Two CPPW grant staff dedicated approximately 25% of their time to the development and implementation of this practice (approximately $45,000). The costs of implementing this practice for another LHD will be directly affected by the number of school districts in their practice area. Our implementation covered 15 school districts. Implementation of this practice by another LHD could range from a single district to more than 100 districts and this would affect the implementation costs proportionately. Also, other LHDs would not incur many of the development costs as the practice tool has already been developed and is available for others to use.
Is there sufficient stakeholder commitment to sustain the practice? Describe how this commitment is ensured. The stakeholders involved in this practice have already expressed the value they have gained in its implementation. Due to the evaluative nature of the practice, it is not one that needs to be sustained continually over time. Rather, a school district could, at any point, decide to code and analyze another year of data to capture additional changes in their school lunch offerings. In that the coding and data entry systems are already developed, it would just be a matter of categorizing any new items added to the menu since 2011, and then entering the planned servings data for four weeks of menus from a representative elementary and middle school from their district. Thus, once the systems are set up, sustainability costs are minimal. Describe plans to sustain the practice over time and leverage resources. TCHD will be continuing to work with our 15 school districts on healthy eating and other related efforts over time. If our stakeholder group identifies an opportune time to add another year to our analysis, TCHD planning and evaluation staff will be available to assist with the process.
Practice Category Choice 1: Chronic Disease (Obesity) Practice Category Choice 2: Practice Category Choice 3: Check all that apply. Colleague in my health department The agency has submitted previously. Are you a previous applicant? No |
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