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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.
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* Indicates required question
Full Name of Requestor
*
Your answer
Email Address
*
Your answer
Role/Job Title
Your answer
Organization
*
Your answer
Street Address
Your answer
City
Your answer
State
*
DE
DC
MD
PA
VA
WV
Other:
Phone Number
Your answer
Date of the request
MM
/
DD
/
YYYY
Type of Request
*
Training
Technical Assistance
Other:
Required
Into which of the following categories do the training or technical assistance activities fall?
*
Check all that apply.
Addiction
Mental Health
Prevention
Other:
Required
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.
Your answer
Goals and/or Desired Outcome
Describe the goals and outcomes you would like to achieve as a result of this T/ TA.
Your answer
Desired start or training date
Is there a specific time-frame or date you would like to begin the T/TA?
Your answer
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
Colleague
Other:
Required
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