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The Region 10 Northwest Addiction Technology Transfer Center (ATTC) serves those in the states of Alaska, Idaho, Oregon, and Washington and is housed at the University of Washington Alcohol & Drug Abuse Institute.

We are currently collecting information from professionals interested in serving as trainers.

Please complete the following personal information to assist new Northwest ATTC staff in contacting you about opportunities.

If you encounter any difficulties submitting this information, please contact us at northwest@attcnetwork.org.

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* 1. I consent to be contacted by the new Northwest ATTC about opportunities to serve as a regional trainer.

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* 2. Full name (including professional degrees/credentials, if any):

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* 3. Employer:

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* 4. Street Address:

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* 5. City:

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* 6. State:

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* 7. Zip:

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* 8. Email:

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* 9. Preferred phone number:

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* 10. Select all areas of subject matter expertise for which you are able to conduct health education events (i.e., webinars, trainings, technical assistance, etc.) for the addiction workforce.

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* 11. If you selected "Prevention/treatment with specific population groups" above, please specify which population groups here.

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* 12. Please enter any additional information about subjects you would be interested in delivering health education events/training about here (including additional details about any topics you selected above that you think might be helpful for us to know!):

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* 13. For what types of health education events are you available? (Check all that apply.)

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* 14. Provided travel expenses were compensated, are you able/willing to conduct health education events elsewhere in our four-state region?

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* 15. If appropriate, are you able/willing to provide a letter of reference from an organization with whom you’ve conducted similar events in the past, and/or enable NWATTC staff to review in advance copies of any proposed materials?

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