Training and Technical Assistance Referral Form for PPTB Staff at CDC Survey

Question Title

* 1. PPTB team (select all that apply):

Team 1

Team 2

Team 3

Other (please specify)

Question Title

* 2. Does this referral apply to a single recipient or to multiple recipients of PPTB funds?

Single recipient

Multiple recipients

Question Title

* 3. TTA recipient 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

* 4. TTA recipient state (select all that apply):

All states

Region 1

Region 2

Region 3

Region 4

Region 5

Region 6

Region 7

Region 8

Region 9

Region 10

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

Florida

Georgia

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

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virginia

Washington

West Virginia

Wisconsin

Wyoming

Puerto Rico

Guam

U.S. Virgin Islands

Northern Mariana Islands

Question Title

* 5. TTA recipient organizational type (check all that apply):

State health department

Local health department

State domestic violence coalition

Question Title

* 6. Role of individual(s) to receive TTA:

Question Title

* 7. Focus of TTA (select all that apply)

Planning

Partnerships

Policy efforts

Strategies and approaches

Adaptation

Implementation

Evaluation

Question Title

* 8. Description of TTA request
Please tell us how we can assist the PPTB recipient(s).

Question Title

* 9. Previous TTA provided
Describe other relevant TTA received by the recipient(s) that would be helpful for meeting the current TTA request.

Question Title

* 10. Measure of success (desired outcome)
Please describe what you would like the recipient(s) to do following receipt of TTA and how this relates to program requirements.

Question Title

* 11. Preferred mode of TTA delivery

Conference calls

Office hours

Peer-to-peer

Community of practice call

Online learning event/webinar

Site visit

In-person TTA for multiple recipients (e.g., regional or national)

New materials/fact sheets

Other (please specify)

Question Title

* 12. Preferred provider(s) (if applicable)

CDC's VPTAC

National Sexual Violence Resource Center

PreventConnect

No preference

Other (please specify)

Training and Technical Assistance Referral Form for PPTB Staff at CDC

Question Title

* 1. PPTB team (select all that apply):

Question Title

* 2. Does this referral apply to a single recipient or to multiple recipients of PPTB funds?

Question Title

* 3. TTA recipient program (select all that apply):

Question Title

* 4. TTA recipient state (select all that apply):

Question Title

* 5. TTA recipient organizational type (check all that apply):

Question Title

* 6. Role of individual(s) to receive TTA:

Question Title

* 7. Focus of TTA (select all that apply)

Question Title

* 8. Description of TTA requestPlease tell us how we can assist the PPTB recipient(s).

Question Title

* 9. Previous TTA providedDescribe other relevant TTA received by the recipient(s) that would be helpful for meeting the current TTA request.

Question Title

* 10. Measure of success (desired outcome)Please describe what you would like the recipient(s) to do following receipt of TTA and how this relates to program requirements.

Question Title

* 11. Preferred mode of TTA delivery

Question Title

* 12. Preferred provider(s) (if applicable)

* 8. Description of TTA request
Please tell us how we can assist the PPTB recipient(s).

* 9. Previous TTA provided
Describe other relevant TTA received by the recipient(s) that would be helpful for meeting the current TTA request.

* 10. Measure of success (desired outcome)
Please describe what you would like the recipient(s) to do following receipt of TTA and how this relates to program requirements.