Release Date:  March 15, 2000

RFA:  OH-00-003

National Institute for Occupational Safety and Health

Letter of Intent Receipt Date:  April 12, 2000
Application Receipt Date:       May 15, 2000


The Centers for Disease Control and Prevention (CDC) announces the 
availability of fiscal year (FY) 2000 funds for cooperative agreement 
(U01) applications from single institutions or consortia of 
institutions who are capable of, and interested in,  participating in a 
Musculoskeletal Disorders Consortium (MSDC).  The goal of the MSDC is 
to conduct a prospective cohort study to quantify the risk for upper 
limb and low back MSDs at varying levels of exposure to physical job 
stressors (repetitive, forceful exertion, awkward postures, vibration, 
manual handling, etc.).  This research will involve multiple work sites 
from the service and manufacturing industries with job tasks that 
represent a  range of exposures to physical job stressors that can 
result in  carpal tunnel syndrome (CTS),  hand-wrist tendinitis, medial 
and lateral epicondylitis, hand-arm vibration syndrome (HAVS), and low 
back pain.


CDC is committed to achieving the health promotion and disease 
prevention objectives of Healthy People 2010, a national activity to 
reduce morbidity and mortality and improve the quality of life.  This 
announcement is related to the focus area of occupational safety and 
health.  For information on the conference on Healthy People 2010,  
visit the internet site:


Applications may be submitted by public and private nonprofit and for-
profit organizations and by governments and their agencies; that is, 
universities, colleges, research institutions, hospitals, other public 
and private nonprofit and for-profit organizations, State and local 
governments or their bona fide agents, including small, minority and/or 
women-owned businesses.  Applications from minority and women 
investigators are encouraged.


The administrative and funding instrument to be used for this program 
will be a cooperative agreement (U01), an assistance mechanism, in 
which substantial NIOSH scientific and/or programmatic involvement with 
the awardee is anticipated during performance of the activity.  Under 
the cooperative agreement, the NIOSH purpose is to support and/or 
stimulate the recipient's activity by involvement in and otherwise 
working jointly with the award recipient in a partner role.  Details of 
the responsibilities, relationships and governance of the study to be 
funded under cooperative agreement(s) are discussed later in this 
document under the section Terms and Conditions of Award.

The total project period for an application submitted in response to 
this present RFA may not exceed five (5) years.  The anticipated award 
date is September 1, 2000.  The award and level of support depends on 
receipt of applications of high scientific merit. 

For this RFA, an applicant may only submit applications that are 
limited in scope to one of the three topics for this RFA.  On the face 
page of the application, line two, the applicant must indicate the 
research area of the 1) upper limb MSDs (CTS, hand-wrist tendinitis, 
epicondylitis) at varying levels of hand activity, exertion, and other 
physical stressors in job tasks; 2) HAVS in relation to use of 
vibrating tools; and 3) low back pain in relation to physical demands 
of lifting and manual handling tasks.  If an applicant wishes to apply 
for more than one research area, you must submit a separate and 
independent application.  Applications which address more than one of 
the RFA topics will be returned as non-responsive.   


Approximately $900,000 is available in FY 2000 to fund three awards.  
The maximum amount that maybe requested is $350,000 total cost (direct 
and facilities and administrative (F&A) costs) per year.  

Continuation awards within an approved project period will be made on 
the basis of satisfactory progress as evidenced by required reports and 
the availability of funds.
Use of Funds

Recipient should allocate funds for travel for two project staff to 
attend annual meeting held during each project year.



Work-related Musculoskeletal Disorders (MSDs) remain a large and costly 
disease to our society even though there have been many advances in 
understanding the ergonomics of work.  In 1996, a total of 600,390 
work-related musculoskeletal injury cases resulting in work absence or 
restriction were reported to be caused by overexertion and repetitive 
motion  by the Bureau of Labor Statistics (BLS).  Because the BLS 
annual survey does not cover approximately one-third of workers, this 
figure significantly underestimates the overall incidence of MSDs in 
the American workforce.  Of all MSD cases, sixty-nine percent were low 
back or distal upper limb disorders.  The magnitude of the problem in 
today’s workforce is confirmed by workers’ compensation data.  For 
instance, in Washington State between 1990 and 1997, 27% of all 
workers’ compensation claims and 46% of the cost of all claims resulted 
from non-traumatic musculoskeletal disorders of the neck, upper 
extremity or back.  The results from this research program will provide 
practitioners in occupational health critical data that will facilitate 
their identification of job tasks that represent low, moderate and high 
risk for MSDs, and that will provide a knowledge base for effective job 
design changes or interventions.  Because of the limitations of cross-
sectional and retrospective studies, it widely agreed that a 
prospective study design is the best approach for this problem.

An integral part of this initiative is the establishment of a 
Musculoskeletal Disorders Consortium (MSDC).  For this program, it is 
important that data elements which will be shared between awardees are 
managed in a uniform and compatible format.  In addition, because much 
of the shared data elements are centered on job tasks and workers, a 
critical role of the MSDC will be to assure that job tasks are studied 
using uniform exposure assessment methods and that workers undergo 
standard health tests to identify MSDs.  In order to accomplish that 
goal, the MSDC will establish a Coordination Committee (CC), comprised 
of one voting representative from each member of the consortium, to 
serve as the main governing board for the conduct of this research 
program.  In addition, the CC will serve as an advisory body for the 
common or shared protocols to be used in the studies.  NIOSH staff will 
serve as non-voting members of the CC.

Through the MSDC, it is anticipated that an outcome of this research 
program will be better defined exposure-response relationships between 
job physical stressors and musculoskeletal disorders across industries.  
These data, when complete, will be used to test and expand existing 
guidelines for limiting exposure to physical job stressors, and for 
developing new guidelines where none exist.  In addition, it is 
anticipated that practitioners in occupational health will be able to 
use the results from this study to more quickly and reliably 
discriminate job tasks that represent low, moderate and high risk for 
MSDs.  With such knowledge effective job design changes or 
interventions can be developed that reduce the burden of work-related 

The MSDC will combine the expertise and resources of NIOSH research 
staff with those of external collaborators.  It is anticipated that 
this consortium will involve up to three extramural partners that 
demonstrate expertise in one or more of the following research areas: 
1) upper limb MSDs (CTS, hand-wrist tendinitis, epicondylitis) at 
varying levels of hand activity, exertion, and other physical stressors 
in job tasks; 2) HAVS in relation to use of vibrating tools; and 3) low 
back pain in relation to physical demands of lifting and manual 
handling tasks.  Individual investigators are encouraged to analyze and 
publish data from the work sites they study as soon as they are able 
to.  In addition, each investigator will be responsible for providing 
data to a data coordinating center in a uniform fashion.  The site for 
the center will be one of the awardees who is selected by CC.  The 
awardee selected as the data center will be allowed to request, for 
consideration of funding, a small administrative supplement to support 
this activity.  This center will serve as the data resource for the 
analysis by the consortium investigators of the pooled data from all 
work sites in collaboration with the MSDC.
Objectives and Scope

The intent of this initiative is to assemble a cross-disciplinary, 
multi-institutional consortium to define the relationships between 
physical job stressors and upper limb and low back MSDs.  To accomplish 
this objective, it is envisioned that the following research areas be 
examined: 1)  upper limb MSDs (CTS, hand-wrist tendinitis, 
epicondylitis) at varying levels of hand activity, exertion, and other 
physical stressors in job tasks; 2) HAVS in relation to use of 
vibrating tools; and 3) low back pain in relation to physical demands 
of lifting and manual handling tasks.  

There is evidence of causal relationships between job physical 
stressors (repetitive or static exertion, forcefulness, awkward 
postures, e.g.) and MSDs, and some quantitative information is 
available on how much rates of MSDs change at varying levels of 
exposure to each stressor and combination of stressors (exposure-
response relationships).  Additional information would foster the 
further development of effective intervention strategies.  It is 
projected that this consortium would consist of three interrelated 
projects previously identified for three independent awards.  It is 
important that the applicant include in their application not only the 
number of subjects to be included in the study, but also a 
justification for the subject number.


National Institute for Occupational Safety and Health.  National 
Occupational Research Agenda. Cincinnati, OH: U.S. Department of Health 
and Human Services, Public Health Service, Centers for Disease Control 
and Prevention, National Institute for Occupational Safety and Health, 
DHHS (NIOSH) Publication No.96-115 

National Institute for Occupational Safety and Health.  Musculoskeletal 
Disorders and Workplace Factors.   Department of Health and Human 
Services, Public Health Service, Centers for Disease Control and 
Prevention, National Institute for Occupational Safety and Health, DHHS 
(NIOSH) Publication No.97-141 (


Applicants with established resources and facilities to recruit study 
sites and to enroll workers willing to participate in the study in a 
cost effective manner are encouraged.

The following should be addressed in a clear and organized manner (see 
also peer review criteria section):
o  Time line: a detailed time line for the proposed study must be 
included in the application.
o  In a separate section labeled ,Participant Notification of Study 
Results, the applicant should describe plans for notifying participants 
about their individual results and the overall results of the study. 

Applicants should highlight unique expertise and/or unusual 
opportunities as related to the purpose of this RFA.  Examples include, 
but are not limited to: 

o  Expertise in specialized areas with potential applications to the 
issues/questions considered in this RFA, such as health effects 
assessment of hand-arm vibration, field studies of working populations 
experiencing work-related MSDs and experience utilizing the NIOSH 
lifting equation;

o  Access to specific work sites and working populations that are 
willing to participate in studies of work-related MSDs;

o  Expertise in assessing work situations and individual job tasks in 
relation to the development of work-related MSDs; and/or

o  Expertise in interviewing workers and negotiating with work site 
management - in field settings.


Applicants should include in their budget support for themselves and 
for at least one other person from their institutions integrally 
involved in the project to attend an annual program meeting of all 
members of the MSDC.  The meeting will be of one or two days duration 
and will be held at a site mutually acceptable to study collaborators.  
The initial meeting will be in Washington, DC.

The applicant should also budget for attendance at four Coordination 
Committee (CC) meetings of the MSDC during the first year and two in 
each subsequent year.  For budget preparation and project planning 
purposes, it should be assumed that these meetings will be held in 
Cincinnati, Ohio.  However, the CC will determine later where and when 
recurring CC meetings will be held.  The CC chair will coordinate the 
meetings to review and assess overall progress and provide the 
opportunity for investigators to exchange information and discuss 
research issues.


The Terms and Conditions of Award, below, will be incorporated in all 
awards issued as a result of this RFA. It is critical that each 
applicant include specific plans for responding to these terms.  These 
special Terms of Award are in addition to and not in lieu of otherwise 
applicable OMB administrative guidelines, HHS Grant Administration 
Regulations at 45 CFR Parts 74 and 92, and PHS Grants Policy Statement.

Under the cooperative agreement, the NIOSH purpose is to support and/or 
stimulate the recipient's activity by involvement in and otherwise 
working jointly with the award recipient in a partner role, but it is 
not to assume direction, prime responsibility, or a dominant role in 
the activity.  Consistent with this concept, the dominant role and 
prime responsibility for the activity resides with the awardee(s) for 
the project as a whole, although specific tasks and activities in 
carrying out the studies will be shared among the awardees and the 
NIOSH collaborators where appropriate, including the following.

1. Recipient Responsibilities

The recipient will coordinate project activities, scientifically and 
administratively at the awardee institution and at the other sites that 
may be supported by sub-contractors to this award.  The applicant will 
have primary authority and responsibility to define objectives and 
approaches;  to plan, conduct, and analyze data; and to publish 
results, interpretations, and conclusions of studies conducted under 
the terms and conditions of the cooperative agreement award.  In 
addition, the applicant is responsible for coordination of the 
individual study with the CC.  Recipient will

a.  enroll and follow-up of the study participants and establish and 
maintain mechanisms to ensure that data collection and management 
procedures have necessary quality control and assure confidentiality of 

b.  provide study participants with individual notification letters 
when medical tests are performed, 

c.  serve as a permanent member of the CC,

d.  develop and submit semiannual progress reports, 

e.  collaborate in the scientific reporting of findings, 

f.  provide program management oversight for the project, and 

g.  notify study participants of the overall study results. 

2.  NIOSH Responsibilities

NIOSH anticipates having substantial scientific programmatic 
involvement during conduct of this activity, through technical 
assistance, advice, and coordination.

a.  serve as a scientific liaison between the awardee and other program 
staff at NIOSH with experience in the occupational health issues of 
MSDs and epidemiology;

b.  provide expert consultation in the area of occupational 

c.  provide technical advice on monitoring of field data collection, 
developing operating guidelines, quality control procedures, and 
developing policies/protocols for dealing with recurrent situations; 

d.  facilitate collaborative efforts to compile and disseminate program 
results through presentations and publications,

e.  assist in the development of human subjects protocols for the CDC 
Institutional Review Board (if required) and in the preparation of OMB 
(and other) clearances that may be required during the conduct of the 

3.  Collaborative Responsibilities

The CC will serve as the main governing board for the cooperative 
agreements making up the MSDC.  NIOSH staff and one external scientist 
at the recipient organizations representing the three project areas 
will have membership on the CC.

One critical role of the CC is to ensure that the study designs and 
data collection protocols are uniform and compatible across the MSDC.

The CC may, when it deems it to be necessary, invite additional, non-
voting scientific advisors to the meetings at which research priorities 
and opportunities are discussed.

It is anticipated that there will be four CC meetings during the first 
year and two in each subsequent year,  but the actual number and 
locations of the meetings will be determined by the CC itself.  The 
initial planning meeting will be organized by NIOSH and held in 
Cincinnati soon after the award, but subsequent meetings will be 
organized by the CC.  The committee chair will schedule the meetings 
and will be responsible for developing the meeting agenda, chairing the 
meetings, and producing CC reports.

At the Planning Meeting, the CC may:
o  discuss the required populations and recruitment approaches to be 
o  discuss and set initial recruiting targets and schedules;

At the second and subsequent meetings, the CC may: 1) make 
recommendations on the study protocols and data collection approaches, 
2) discuss the study populations that have been/will be recruited for 
the three studies, 3) identify and recommend solutions to unexpected 
study problems and 4) discuss ways to efficiently coordinate and 
combine common study activities.


If a project involves research on human subjects, assurance (in 
accordance with Department of Health and Human Services Regulations, 45 
CFR Part 46) of the protection of human subjects is required.  In 
addition to other applicable committees, Indian Health Service (IHS) 
institutional review committees also must review the project if any 
component of IHS will be involved with or will support the research.  
If any American Indian community is involved, its tribal government 
must also approve that portion of the project applicable to it.  Unless 
the grantee holds a Multiple Project Assurance, a Single Project 
Assurance is required, as well as an assurance for each subcontractor 
or cooperating institution that has immediate responsibility for human 
subjects.  The Office for Protection from Research Risks (OPRR) at the 
National Institutes of Health (NIH) negotiates assurances for all 
activities involving human subjects that are supported by the 
Department of Health and Human Services.


It is the policy of the Centers for Disease Control and Prevention 
(CDC) to ensure that individuals of both sexes and the various racial 
and ethnic groups will be included in CDC-supported research projects 
involving human subjects, whenever feasible and appropriate. Racial and 
ethnic groups are those defined in OMB Directive No. 15 and include 
American Indian or Alaska Native, Asian, Black or African American, 
Hispanic or Latino, Native Hawaiian or Other Pacific Islander.  
Applicants shall ensure that women, racial and ethnic minority 
populations are appropriately represented in applications for research 
involving human subjects.  Where clear and compelling rationale exist 
that inclusion is inappropriate or not feasible, this situation must be 
explained as part of the application.  This policy does not apply to 
research studies when the investigator cannot control the race, 
ethnicity, and/or sex of subjects.  Further guidance to this policy is 
contained in the Federal Register, Vol. 60, No. 179, pages 47947-47951, 
and dated Friday, September 15, 1995.


Prospective applicants are asked to submit, by April 12, 2000, a letter 
of intent that includes a descriptive title of the proposed research, 
name, address, and telephone number of the Principal Investigator, 
identities of other key personnel and participating institutions, and 
number and title of the RFA in response to which the application may be 

Although a letter of intent is not required, is not binding, and does 
not enter into the review of subsequent applications, the information 
allows NIOSH staff to estimate the potential review workload and to 
avoid conflict of interest in the review.

The letter of intent is to be sent to:

Ann M. Cronin
National Institute for Occupational Safety and Health
Centers for Disease Control and Prevention
1600 Clifton Road, N.E.
Building 1, Room 3070B, MS D-40
Atlanta, GA  30333
Telephone 404-639-2277
Fax 404-639-0035


Applicants must use Form PHS 398 (rev. 4/98).  Application kits are 
available at most institutional offices of sponsored research and may 
be obtained from the Division of Extramural Outreach and Information 
Resources, National Institutes of Health, 6701 Rockledge Drive, MSC 
7910, Bethesda, MD 20892-7910, telephone 301/710-0267, Email:  Application kits are also available at:

The RFA label available in the PHS 398 (rev. 4/98) application form 
must be affixed to the bottom of the face page of the application.  
Failure to use this label could result in delayed processing of the 
application such that it may not reach the review committee in time for 
review.  In addition, the RFA title and number must be typed on line 2 
of the face page of the application form and the YES box must be 

The sample RFA label available at: has been modified to 
allow for this change.  Please note this is in pdf format.

Submit a signed original of the application, including the Checklist, 
and three signed photocopies, in one package to:

Center for Scientific Review (CSR)
National Institutes of Health
6701 Rockledge Drive, Room 1040 - MSC 7710
Bethesda, MD  20892-7710
Bethesda, MD  20817 (for express/courier service)

At the time of submission, two additional copies of the application 
must also be sent to:

Ann M. Cronin
National Institute for Occupational Safety and Health
Centers for Disease Control and Prevention
1600 Clifton Road, N.E.
Building 1, Room 3070B, MS D-40
Atlanta, GA  30333

Applications must be received by May 15, 2000.   If an application is 
received after that date, it will be returned to the applicant without 
review.  CSR and NIOSH will not accept any application in response to 
this RFA that is essentially the same as one currently pending initial 
review, unless the applicant withdraws the pending application.  CSR 
and NIOSH will not accept any application that is essentially the same 
as one already reviewed.  This does not preclude the submission of a 
substantial revision of an application already reviewed, but such an 
application must follow the guidance in the PHS Form 398 application 
instructions for the preparation of revised applications, including an 
introduction addressing the previous critique.


Upon receipt, applications will be reviewed for completeness by CSR and 
responsiveness by NIOSH.  Incomplete and/or non-responsive applications 
will be returned to the applicant without further consideration.  Those 
applications that are complete and responsive, will undergo further 
scientific merit review in accordance with the criteria stated below 
for scientific/technical merit by an appropriate peer review group 
convened by NIOSH.

All applications will be judged on the basis of the scientific merit of 
the proposed project and the documented ability of the investigators to 
meet the RESEARCH OBJECTIVES of the RFA.  Although the technical merit 
of the proposed protocol is important, it will not be the sole 
criterion for evaluation of a study.  Other considerations, such as the 
importance and timeliness of the proposed study, access to the study 
population, and the interdisciplinary nature of the studies, will be 
part of the evaluation criteria.

As part of the initial merit review, all applications will receive a 
written critique and undergo a process in which only those applications 
deemed to have the highest scientific merit, generally the top half of 
the applications under review, will be discussed, assigned a priority 
score, and receive a second level review.

Following the scientific review, competitive applications will be 
reviewed for programmatic importance by a NIOSH Secondary Review 

Peer Review Criteria

Applicants are encouraged to submit and describe their own ideas about 
how best to meet the goals of the cooperative study and their specific 
protocols and are expected to address issues identified under SPECIAL 
CONSIDERATIONS AND REQUIREMENTS of the RFA. The review group will 
assess the scientific merit of the protocols and related factors as 

Significance:  Does this study address an important problem in the area 
of work-related musculoskeletal disorders?  If the aims of the 
applications are achieved, how will scientific knowledge be advanced?  
What will be the effect of these studies on the concepts or methods 
that drive this field?

Approach:  Are the conceptual framework, design, methods, and analyses 
adequately developed, well-integrated, and appropriate to the aims of 
the project?  Does the applicant acknowledge potential problem areas 
and consider alternative tactics?  Are the plans for the recruitment 
and retention of subjects adequate?  Is there adequate consideration of 
follow up of study participants?  Is the plan for assembling work sites 
and participants suitable for this study?  Is the time line for the 
studies appropriate and well described?   Are the methods for assuring 
privacy and maintaining confidentiality of participant records, 
including specific protections for computerized data systems adequate?

Innovation:  Does the project employ novel concepts, approaches, or 
methods? Are the aims original and innovative?  Does the project 
challenge existing paradigms or develop new methodologies or 

Investigators: Are the Principal Investigator, Co-Principal 
Investigators and their teams appropriately trained and have adequate 
experience to carry out this work?  Is the work proposed appropriate to 
the experience level of the principal investigator and his/her 

Environment:  Does the scientific environment in which the work will be 
done significantly contribute to the probability of success?  Do the 
proposed experiments take advantage of unique features of the 
scientific environment or employ useful collaborative arrangements?  Is 
there evidence of institutional support?  Does the proposed project 
utilize an existing resource or constitute a new one?

In addition to the above criteria, all applications will also be 
reviewed with respect to the following:

o  The reasonableness of the proposed budget and duration in relation 
to the proposed research.

o  The adequacy of plans to include both genders, minorities and their 
subgroups, for the scientific goals of the research.

o  The adequacy of the proposed protection for humans, animals or the 
environment, to the extent they may be adversely affected by the 
project proposed in the application.

Programmatic Review Criteria:

o  Magnitude and severity of the problem the worker population.

o  Likelihood of developing technical knowledge for the prevention of 
occupational safety and health hazards on a national or regional basis.


Applications will be considered for award based upon (a) scientific and 
technical merit, (b) program importance, (c) program balance (at least 
one award will be made for each area), and (d) availability of funds.


Letter of Intent Receipt Date:  April 12, 2000
Application Receipt Date:       May 15, 2000
Anticipated Award Date:         September 1, 2000


Written and telephone inquiries concerning this RFA are encouraged.  
The opportunity to clarify any issues or questions from potential 
applicants is welcome.

Direct inquiries regarding programmatic issues to:

Michael J. Galvin, Jr. Ph.D.
Research Grants Program
National Institute for Occupational Safety and Health
Centers for Disease Control and Prevention
1600 Clifton Road, N.E.
Building 1, Room 3053, MS D-30
Atlanta, GA  30333
Telephone: 404/639-3343
FAX: 404/639-4616

Direct inquiries regarding grants management to:

Sheryl L. Heard, Grants Management Specialist
Grants Management Branch, Procurement and Grants Office
Announcement 00044
Centers for Disease Control and Prevention 
2920 Brandywine Road, Room 3000
Atlanta, Georgia 30341
Telephone: (770) 488-2723
Email address:


Projects that involve the collection of information from 10 or more 
individuals and funded by cooperative agreement will be subject to 
review by the Office of Management and Budget (OMB) under the Paperwork 
Reduction Act.


The Catalog of Federal Domestic Assistance number is: 93.262 for the 
National Institute for Occupational Safety and Health (NIOSH).  This 
program is authorized under the Public Health Service Act, as amended, 
Section 301(a) [42 U.S.C. 241(a)], and the Occupational Safety and 
Health Act of 1970, Section 20(a) [29 U.S.C. 669(a)].  The applicable 
program regulation is 42 CFR Part 52.   

Applicants should be aware of restrictions on the use of HHS funds for 
lobbying of Federal or State legislative bodies. Under the provisions 
of 31 U.S.C. Section 1352, recipients (and their sub-tier contractors) 
are prohibited from using appropriated Federal funds (other than 
profits from a Federal contract) for lobbying congress or any Federal 
agency in connection with the award of a particular contract, grant, 
cooperative agreement, or loan. This includes grants/cooperative 
agreements that, in whole or in part, involve conferences for which 
Federal funds cannot be used directly or indirectly to encourage 
participants to lobby or to instruct participants on how to lobby.

In addition no part of CDC appropriated funds, shall be used, other 
than for normal and recognized executive-legislative relationships, for 
publicity or propaganda purposes, for the preparation, distribution, or 
use of any kit, pamphlet, booklet, publication, radio, television, or 
video presentation designed to support or defeat legislation pending 
before the Congress or any State or local legislature, except in 
presentation to the Congress or any State or local legislature itself. 
No part of the appropriated funds shall be used to pay the salary or 
expenses of any grant or contract recipient, or agent acting for such 
recipient, related to any activity designed to influence legislation or 
appropriations pending before the Congress or any State or local 


The CDC strongly encourages all grant and contract recipients to 
provide a smoke-free workplace and promote the non-use of all tobacco 
products.  In addition, Public Law 103-227, the Pro-Children Act of 
1994, prohibits smoking in certain facilities (or in some cases, any 
portion of a facility) in which regular or routine education, library, 
day care, health care, or early childhood development services are 
provided to children.  This is consistent with the CDC mission to 
protect and advance the physical and mental health of the American 

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