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Training and Technical Assistance Request Form for Recipients of PPTB Funds
*
1.
PPTB 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)
*
2.
State
(Required.)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia (DC)
Florida
Georgia
Guam
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
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
U.S. Virgin Islands
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
3.
Organizational type:
State health department
Local health department
State domestic violence coalition
*
4.
Role of individual(s) to receive TTA
(Required.)
Director
Coordinator
Program Manager
Evaluator
Program Support Staff
Principal Investigator
5.
Detailed request
Please tell us how we can assist you.
6.
Preferred mode of TTA delivery (select all that apply)
Conference calls
Email
Office hours
Peer-to-peer
Community of practice call
Online learning event/webinar
Other (please specify)
7.
Preferred TTA provider(s) (select all that apply)
CDC's VPTAC
National Sexual Violence Resource Center
PreventConnect
No preference
Other (please specify)
Current Progress,
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