Road Safety Champion Program: Module Request Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Thank you for your interest the Road Safety Champion Program! At this time, materials are available for distribution to LTAP/TTAP Centers only*. If you are a current LTAP/TTAP staff member or instructor, please complete this form to register for the course materials. We will follow up within two business days with the login info or any questions.

*If you are not affiliated with LTAP/TTAP and would like to request access to the RSCP modules, please email Janet Leli, Training Manager at: janet@ruralsafetycenter.org

As always, if you have questions, please contact us anytime at info@ruralsafetycenter.org.

Email *

LTAP/TTAP Name *

LTAP/TTAP Address *

Name of Requestor *

Title of Requestor *

Phone of Requestor *

Secondary Contact

Is your LTAP/TTAP *

University based?

DOT based?

Other:

Required

Does your LTAP/TTAP have a safety circuit rider?
*

Yes

Required

Does your LTAP/TTAP have a road scholar program?
*

Yes

Required

The RSCP is a flexible program designed for ease of incorporation into activities the LTAPs and TTAPs are already providing. Which of the following best describes how you anticipate using the program? Select all that apply.
*

Deploy/host the entire Level 1 certificate program

Deploy/host individual modules on an as needed basis

Integrate content from modules into existing LTAP/TTAP training materials

All of the above

Other:

Required

The RSCP is a flexible program designed for multiple delivery methods. Which of the following best describes how you anticipate using the program?
*

In-person

Virtual, instructor-led

Virtual, on demand

Other:

How soon do you anticipate beginning deployment of the RSCP (in any format)?
*

1-3 months

3-6 months

6-9 months

9-12 months

12 months or longer

Required

We’ll want to capture class roster and course evaluation data from your use of the RSCP modules for our required reporting to FHWA; please share this within 30 days of your training event. We'll also contact you on a bi-annual basis to obtain your feedback on the RSCP. This includes your perspectives on the training, its general impact, and specific module improvements. In addition to your specific RSCP comments, we'd like to hear from you on how the RRSC can best help your center, and LTAP/TTAP in general.

Please provide any additional questions, comments, or feedback on the RSCP you may have:

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms