641—151.4 (142A) Application requirements for community partnerships. In order to qualify for funding through the tobacco use prevention and control program, a public agency or nonprofit organization seeking to be designated as a community partnership must apply to, and be approved by, the department of public health. Only one application per community partnership will be accepted. An application must provide the following information:
	   151.4(1) A description of the community partnership area to be served by the community partnership, including:
	      a.    	 The geographic boundaries of the area;
	      b.    	 Population, including both general population and school-age population, of the area;
	   151.4(2) A description of the applicant, including a description of the governing structure of the agency or organization, a table of organization, and the applicant’s mission statement;
	   151.4(3) A description of the tobacco use prevention and control services currently provided by the applicant;
	   151.4(4) A description of the community outreach and educational programming services currently provided by the applicant;
	   151.4(5) A description of the number of years the applicant has provided tobacco use prevention and control services and the number of clients served annually by the applicant;
	   151.4(6) A description of the funds currently received by the applicant which are targeted to provide tobacco use prevention and control services, including the source of funds, the dollar amount, and the period of funding;
	   151.4(7) A list of the other agencies, organizations, and entities currently providing tobacco use prevention and control services in the proposed community partnership area and a description of the tobacco use prevention and control services currently provided by the other agencies, organizations, or entities;
	   151.4(8) A description of the collaborative efforts the applicant has undertaken with the agencies, organizations, and entities described in subrule 151.4(6) and an action plan describing anticipated collaborative efforts during the funding period;
	   151.4(9) An assessment of the needs of the community partnership area which incorporates, but is not limited to, the following information for each county in the community partnership area:
	      a.    	 Tobacco-related information from the community health needs assessment and health improvement plan (CHNA and HIP, Healthy Iowans);
	      b.    	 Tobacco-related information from the most recent Iowa youth survey;
	      c.    	 Relevant data regarding tobacco use;
	      d.    	 Relevant Synar data;
	      e.    	 Information or data received from other service providers, organizations, or law enforcement agencies;
	   151.4(10) A description of how the applicant intends to implement the initiative’s goals described in Iowa Code section 142A.6(2) in light of the community needs identified in subrule 151.4(11), including a proposed budget and a description of how performance measures shall be developed and utilized;
	   151.4(11) Identification of the source and amount of local matching funds, services, or support;
	   151.4(12) A description of how youth (aged 5 to 24 years) will be involved in the community partnership.
[ARC 1225C, IAB 12/11/13, effective 1/15/14]