TA/Training Request Form for the Community Prevention Initiative (CPI) CPI offers Continuing Education Units through the California Association of Marriage and Family Therapists (CAMFT), the California Consortium of Addiction Programs and Providers (CCAPP), and the California Board of Registered Nursing (BRN). Step 1 of 3 33% * indicates required fieldFirst Name*Last Name*Title*Organization*Address Line 1*Address Line 2City*Zip Code*County*Select a countyAlamedaAlpineAmadorButteCalaverasColusaContra CostaDel NorteEl DoradoFresnoGlennHumboldtImperialInyoKernKingsLakeLassenLos AngelesMaderaMarinMariposaMendocinoMercedModocMonoMontereyNapaNevadaOrangePlacerPlumasRiversideSacramentoSan BenitoSan BernardinoSan DiegoSan FranciscoSan JoaquinSan Luis ObispoSan MateoSanta BarbaraSanta ClaraSanta CruzShastaSierraSiskiyouSolanoSonomaStanislausSutterTehamaTrinityTulareTuolumneVenturaYoloYubaStateCaliforniaPhone*FaxOtherEmail* Website Are you asking for TTA as a representative of the California Department of Health Care Services (DHCS)?*YesNoIs the requesting organization a county AOD office, or prevention provider for their county providing substance use disorder prevention services?*(Select one)YesNoNot sureWill the requesting organization (applicant) be receiving the TA/training services directly?*(Select one)YesNoMultiple organizations will receive services1. Please check the categories that best describe your organization:*(Select all that apply) County AOD office County Dept. (other) County AOD, Prevention Provider City Agency State Agency Law Enforcement Religious Organization Clinic/Community Health Center Hospital/Health Service Community Based Org, 501(c) 3 School (k-12) College Business (private) Coalition/Community Partnership How did you hear about CPI TA services?(Select all that apply) Workshops/Brochure County Alcohol and Drug Program Dept. of Health Care Services (DHCS) Colleague Previous Utilization Regional Trainers Consultant Internet Other Have you ever received TA/training services through an ADP or DHCS funded contract?(Select one)YesNoB. TECHNICAL ASSISTANCE INFORMATION1. What kind of assistance is needed?*(Select all that apply) Professional Competency Training Customized training Consultation Facilitation Product Development Information Referral 2. Please describe the problem/issue that your organization seeks to address through this technical assistance or training (please note if this is a continuation of a previously received TA assignment).3. What are the specific outcomes to be achieved as a result of receiving technical assistance or training?a.b.c.4. Do you have a proposed timeline for the start of requested TA?*(Select one)YesNoIf yes, when would it be (for training events, please note 2-3 date possibilities)?5. Approximately how many individuals will participate in the TA or training service?*6. Please identify the population(s) of the participants that will attend this TA/training.(Select all that apply) African American Asian American Caucasian Hispanic/Latino Native American Pacific Islander No specific group Other Are there any cultural and/or linguistic needs regarding your community, organization or program participants that you would like addressed in this TA?*(Select one)YesNoIf yes, please specify:7. Where will TA/training service occur?9. Are you requesting a specific consultant?*(Select one)YesNoIf yes, please specify:10. Does your organization have resources to pay for or share the cost of the technical assistance or training services?*(Select one)YesNoIf yes, please mark all that apply:(Select all that apply) Funding for Consultation fee Photocopying for training/TA materials Consultant Travel Costs Refreshments (water, juice, fruit, etc.) Room and IT equipment Other 11. To the best of your ability, please identify which portion of the Strategic Prevention Framework (SPF) process you believe your organization/dept/coalition is addressing through this TA request:(Select all that apply) Assessment: Profile population needs, resources, and readiness to address the problems and gaps in service delivery Capacity: Mobilize and/or build capacity to address needs Planning: Develop a Comprehensive Strategic Plan Implementation: Implement evidence-based prevention programs and infrastructure development activities Evaluation: Monitor process, evaluate effectiveness, sustain effective programs/activities, and improve or replace those that fail 12. The SPF process also includes Cultural Competence and Sustainability as important factors that cross all phases of the process. Please indicate if this TA request will address:(Select all that apply) Cultural Competence: A system of policies, skills and attitudes that eliminates service and participation disparities for people of diverse racial, ethnic, and linguistic populations, as well as consideration of gender, disabilities, and sexual orientation. Sustainability: The essence of sustainability is integrating newly developed approaches into the fabric of existing support programs and services designed to enhance outcomes for children, youth, and communities. Training from Workshop Series Request Details* indicates required fieldThe following questions are being asked because you are requesting "Prevention Extension (PX) Workshop" training:Please choose workshop(s) you would like to host/sponsor.*(Select all that apply) Core Competency Training Series: Assessment Core Competency Training Series: Capacity Building Core Competency Training Series: Planning Core Competency Training Series: Implementation Core Competency Training Series: Evaluation Engaging Youth And Families: Culturally Competent Recruitment and Retention Strategies From Risk To Resilience: Inside-Out Prevention Media Advocacy Basics Environmental Prevention 101: Covering the Basics Environmental Prevention: Strategies for Engaging Youth Community Action to Reduce Binge Drinking Responsible Beverage Service Creating a Safe and Effective Mentoring Program Foster Youth Mentorship Training for Program Managers Mentoring Program Basics Preparing Mentees for Success: A Program Manager's Guide Risk Management for Mentoring Programs Grant Writing: Developing And Maintaining SUD Prevention Programs Part I & Part II Introduction to Substance Abuse Prevention Prevention Theories and Frameworks Enhancing Sustainability Through Capacity Building Youth in Focus: Conducting Youth-Led Focus Groups Brief Intervention For Substance Using Adolescents Click here to view the PX Workshops page for a complete list of available trainings.Are there any topics in the proposed training workshop that you want emphasized by the trainer?Would you be interested in having a follow-up training with some of the participants?*(Select one)YesNoIf yes, please describe:Who will be attending the workshop?*(Select all that apply) Community members Prevention staff CBO staff County ADP staff Other C. Workshop BackgroundIf other, please specifyHas training on this topic been offered to the proposed participants before?(Select one)YesNoIf yes, what were the outcomes?Are there any current prevention projects or community efforts that could be used as examples by the trainer?*(Select one)YesNoIf yes, please describe: You are almost done!Please review the following information and then hit submit to complete the request form.* indicates required fieldPrevention Extension Workshop Request An important note about evaluation: CARS is committed to ensuring the integrity, relevance and quality of our services. All TA and training services are evaluated in accordance with our funder. As a recipient of services, you will be required to participate in evaluation measures that will vary based on the type of training or TA you receive. PX Training: By accepting a PX Training, you agree to complete all evaluation documents and return to CPI within 2 weeks after receipt. TA or Customized Training: You can expect to receive an evaluation survey shortly after services are received, and again 60-90 days post. A Summary Report of the TA services, prepared by the consultant, will also accompany the "post" evaluation. We appreciate your diligence in completing these quick surveys and hope the Summary Report provides your organization with helpful insights and recommendations. In addition, all TA services designated as trainings are evaluated on-site by the participants; distribution and collection of these evaluations is the responsibility of the consultant.Acknowledgement* I have read and accept the above