Training and Technical Assistance Referral Form for PPTB Staff at CDC
A brief tutorial video about the
Training and Technical Assistance Referral Form for PPTB Staff at CDC
is available
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1.
PPTB team (select all that apply):
Team 1
Team 2
Team 3
Other (please specify)
2.
Does this referral apply to a single recipient or to multiple recipients of PPTB funds?
Single recipient
Multiple recipients
*
3.
TTA recipient program (select all that apply):
(Required.)
DELTA Impact
Essentials for Childhood
Preventing Violence Affecting Young Lives (PREVAYL)
Rape Prevention and Education
Preventing Adverse Childhood Experiences: Data to Action (PACE:D2A)
*
4.
TTA recipient state (select all that apply):
(Required.)
All states
Region 1
Region 2
Region 3
Region 4
Region 5
Region 6
Region 7
Region 8
Region 9
Region 10
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Guam
U.S. Virgin Islands
Northern Mariana Islands
5.
TTA recipient organizational type (check all that apply):
State health department
Local health department
State domestic violence coalition
*
6.
Role of individual(s) to receive TTA:
(Required.)
Director
Coordinator
Program Manager
Evaluator
Program Support Staff
Principal Investigator
*
7.
Focus of TTA (select all that apply)
(Required.)
Planning
Partnerships
Policy efforts
Strategies and approaches
Adaptation
Implementation
Evaluation
Other topics (please specify)
*
8.
Description of TTA request
Please tell us how we can assist the PPTB recipient(s).
(Required.)
9.
Previous TTA provided
Describe other relevant TTA received by the recipient(s) that would be helpful for meeting the current TTA request.
10.
Measure of success (desired outcome)
Please describe what you would like the recipient(s) to do following receipt of TTA and how this relates to program requirements.
11.
Preferred mode of TTA delivery
Conference calls
Email
Office hours
Peer-to-peer
Community of practice call
Online learning event/webinar
Site visit
In-person TTA for multiple recipients (e.g., regional or national)
New materials/fact sheets
Other (please specify)
12.
Preferred provider(s) (if applicable)
CDC's VPTAC
National Sexual Violence Resource Center
PreventConnect
No preference
Other (please specify)
Current Progress,
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