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Home
Technical Assistance Request Form
Technical Assistance Request Form
Name
*
Title/Position
*
Organization
*
Email
*
Phone
*
As we have questions, what is the best way to get a hold of you?
*
Please select one
Email
Mail
Phone
Text
Same email as above?
*
Yes
No
Preferred Contact Email
*
Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Same phone as above?
*
Yes
No
Preferred Contact Phone
*
Type of Assistance Requested
*
Data
Evaluation
Program Support
Product Development
Training
Grant Specific TA (e.g., MSPI/DVPI, Tribal Prep, ACORNS, Comp Cancer, Native Connections, Project Pathway)
Other
Topic of Assistance Requested
*
Select all that apply.
Access to data
Community assessment
Data collection
Data analysis
Data interpretation and dissemination
Data management and use
Health messaging
Outbreak response
Program evaluation
Evaluation plan development
Resource development (e.g., survey development, tracking logs)
Surveillance
Training (in person or webinar)
Quality improvement/Process improvement
Other
Other, Please Describe
*
Brief Description
*
e.g., how will the technical assistance benefit your organization/program/community(ies)
Which tribes will benefit from this technical assistance request?
*
Please list all tribes or tribal consortia that this request will serve.
When does the technical assistance request need to be complete?
*
Date Format: MM slash DD slash YYYY
How did you hear about CTEC services?
*
e.g., Indian Health Service, California Rural Indian Health Board, Inc., Indian Health Program, etc.
Questions? Email us at
[email protected]
or give us a call at (916)929-9761 ext. 1550.
Name
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