Training and Technical Assistance Request Form for Recipients of PPTB Funds

Question Title

* 1. PPTB Program (select all that apply)

DELTA Impact

Essentials for Childhood

Preventing Violence Affecting Young Lives (PREVAYL)

Rape Prevention and Education

Preventing Adverse Childhood Experiences: Data to Action (PACE:D2A)

Question Title

* 2. State

Question Title

* 3. Organizational type:

State health department

Local health department

State domestic violence coalition

Question Title

* 4. Role of individual(s) to receive TTA

Question Title

* 5. Detailed request
Please tell us how we can assist you.

Question Title

* 6. Preferred mode of TTA delivery (select all that apply)

Conference calls

Office hours

Peer-to-peer

Community of practice call

Online learning event/webinar

Other (please specify)

Question Title

* 7. Preferred TTA provider(s) (select all that apply)

CDC's VPTAC

National Sexual Violence Resource Center

PreventConnect

No preference

Other (please specify)

Training and Technical Assistance Request Form for Recipients of PPTB Funds

Question Title

* 1. PPTB Program (select all that apply)

Question Title

* 2. State

Question Title

* 3. Organizational type:

Question Title

* 4. Role of individual(s) to receive TTA

Question Title

* 5. Detailed requestPlease tell us how we can assist you.

Question Title

* 6. Preferred mode of TTA delivery (select all that apply)

Question Title

* 7. Preferred TTA provider(s) (select all that apply)

* 5. Detailed request
Please tell us how we can assist you.