A brief tutorial video about the Training and Technical Assistance Referral Form for PPTB Staff at CDC is available here.

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

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

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

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

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

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

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

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

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* 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.

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* 11. Preferred mode of TTA delivery

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

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