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| First Name* | |
| Last Name* | |
| Title* | |
| Organization* | |
| Address Line 1* | |
| Address Line 2 | |
| City* | |
| Zip Code* | |
State | California |
| Phone* | ( ) - Ext: |
|
| Fax | ( ) - |
| Other | ( ) - |
| Email* | |
| Website | |
| Is the requesting organization a county AOD office, or prevention provider for their county providing substance abuse prevention services?* |
Yes No Not sure |
| Will the requesting organization (applicant) be receiving the TA/training services directly?* |
Yes No Multiple organizations will receive services |
| 1. Please check the categories that best describe your organization:* |
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) Business (private) Coalition/Community Partnership |
| How did you hear about CPI TA services? |
Workshops/Brochure County Alcohol and Drug Program State Dept. of Alcohol and Drug Programs Colleague Previous Utilization Regional Trainers Consultant Internet Other: |
| Have you ever received TA/training services through an ADP funded contract? |
Yes No |
|
Please identify the types of TA/training services that will best address your needs. |
| 1. What kind of assistance is needed? (Check all that apply) |
Training (from workshop series) 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). |
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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 timeframe for the requested TA? * |
Yes No |
| If yes, when would it be (for training events, please note 2-3 date possibilities)? |
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| 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. |
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?* |
Yes No |
| If yes, plese specify | |
| 7. Where will TA/training service occur? |
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| 8. If you are requesting a specific training, please utilize the 2010 CPI Catalog to ensure you are providing the exact training name. | |
| What categories of professionals will be attending the training (e.g. administrators, service providers)? Provide
as much detail as you know. |
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| 9. Are you requesting a specific consultant?* |
Yes No |
| If yes, please specify: | |
| 10. Does your organization have resources to pay for or share the cost of the technical assistance or training services?* |
Yes No |
| If yes, please mark 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: |
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
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| 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: |
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. |
| Please provide any other information that would be useful for us to know regarding your request for TA and/or
training services. |
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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. 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.
Thank You |
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