Training and Technical Assistance Request Form
Please complete and submit this form to request training (T) or technical assistance (TA). A member of our team will respond to you shortly.
Full Name of Requestor
Date of the request
Type of Request
Into which of the following categories do the training or technical assistance activities fall?
Check all that apply.
Training / TA needed
Please be as specific and concise as possible. Provide any background information on the issue for which T/TA is being requested.
Goals and/or Desired Outcome
Describe the goals and outcomes you would like to achieve as a result of this T/ TA.
Desired start or training date
Is there a specific time-frame or date you would like to begin the T/TA?
How did you hear about this Training and TA resource?
Danya Institute website
Central East ATTC website (Addiction Technology Transfer Center)
Central East MHTTC website (Mental Health Technology Transfer Center)
Central East PTTC website (Prevention Technology Transfer Center)
Newsletter / Email
Webinar or other event
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