May 29, 2022
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Your Name
*
Your Email
*
Enter Email
Confirm Email
For which of the following are you providing information?
*
Event - Website posting and/or GPRA Request
Website posting - Product or Resource
Website posting - News Announcement
Project that is not a website posting (i.e., 508 compliance or branding for powerpoint slides, documents, etc; requesting closed-captioning)
Project other than what is listed above (anything else that doesn't appear to fall into the above categories)
Due date:
*
When do you want this information posted to the website or the project completed by? (GPRA due dates will be addressed later in this form)
MM slash DD slash YYYY
Date
Post on, or before the above date.
Post ON the above date, exactly.
Event Posting
Would you like this event posted on the Mountain Plains ATTC site?
*
Yes
No
Website Calendar
Would you like this event to be displayed on the event calendar?
*
Yes
No
Title of Event
What is the name of your event?
*
Date & Time
Would you like to display the end date and time on the event page?
*
Yes
No
Is this an Ongoing event?
*
Example: An online, self paced, course that is accessible at any time is considered "ongoing".
Yes
No
If this is an "ongoing" event that does not have a start or end date, consider using the dates of the grant/contract.
Start Date
*
MM slash DD slash YYYY
Start Time
*
Please include AM/PM
End Date
*
MM slash DD slash YYYY
End Time
*
Please include AM/PM
Time Zone
*
US/Mountain
US/Central
Event Description and General Info
Provide a brief description of the event.
*
This description will be posted on the MPATTC website. Please write in full sentences and include speaker names here if you would like them in the web promotion.
How many credit hours will this event include?
*
Event Leader/Contact Person's Name
*
Event Leader/Contact Person's Email
*
List any co-sponsors for this event (if applicable.)
Event Type and Location
What type of event is this?
*
Online Course
Face-to-Face Training
Webinar/Virtual Training
Meeting
Virtual TA Session
Presentation
Virtual Job Fair
Conference
Project Echo
Online Video
Other
Please Describe:
Is this an In-Person event?
*
Yes
No
What is the estimated number of participants?
*
What is the location of the event?
*
City
State / Province / Region
Do you need to provide a physical location/address for this event?
*
Yes
No
Venue Name
*
Event Address
*
Street Address
Address Line 2
City
State
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
ZIP Code
Reporting Information
Which of the following types of technical assistance best describes this event?
*
Universal: information provided to independent users through their own initiative, resulting in minimal interaction with TTC staff. Examples: Mass mailings, publication of information (e.g. newsletters,) untargeted presentations to heterogenous groups, website, social media.
Targeted: Based on needs common to multiple recipients and not extensively individualized. A relationship is established between the TA recipient and one or more TTC staff. Examples: Online courses, webinar series for specialized groups, focused knowledge-sharing, communities of practice, short-term training, replication guides.
Intensive: Requires a stable, ongoing relationship between the TTC program staff and the TA recipient and is provided in accordance with a plan developed between the TTC and the TA recipient. Examples: Ongoing consultation in specific communities, states & systems.
N/A
Do you want to build upon an existing event?
*
This is for reporting purposes only...is this event related in some way to another event?
Yes
No
Previous Event Name
Do you want to attach a document?
*
Yes
No
Upload your file for this Event Posting:
You can upload multiple documents. Files must be smaller than 16MB.
Drop files here or
Select files
Max. file size: 16 MB, Max. files: 6.
Registration
Registration Deadline
MM slash DD slash YYYY
Registration URL
Event Contact Email
*
For registrants
SAMHSA Updates
Should this event be included in SAMHSA's bi-monthly update?
*
Yes
No
SAMHSA's Bi-Monthly Report Relation? (Event)
Please check all that apply:
COVID-19
Recovery Month 2021
Rural Communities
Intensive TA Efforts
Opioid Epidemic
Stimulants
Tribal Communities
N/A
Is this event GPRA'd or non-GPRA'd?
*
GPRA (R8 ATTC Generated)
GPRA (Other TTC Generated)
Non-GPRA
Will these GPRAs be shared with another TTC?
Yes
No
Please list which TTC(s) below;
GPRA Request
Contact Person for GPRA Request
*
Contact Email Address
*
Name of Trainer/Facilitator
*
Delivery Method
*
Online
Face-to-face
Date needed by
*
Date GPRAs are needed in hand, not the same as date of training.
MM slash DD slash YYYY
To whom will the package be shipped? (name of person)
*
Address to ship to
*
Street Address
Address Line 2
City
State
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
ZIP Code
Additional person you would like to receive the GPRA link
Please provide email address
Second additional person you would like to receive the GPRA link
Third additional person you would like to receive the GPRA link
Do you need a trainer feedback summary report?
*
Yes
No
Basic Product/Resource Info
What is the title/name of your product/resource?
*
Please provide a brief description of your product/resource.
*
Type of product/resource?
*
Toolkit
Print Media (Brochure, Monograph, Report, Poster)
Video or Multimedia
Website
Curriculum Package
eNewsletter or Blog
Interactive Resources
Mobile App
Presentation Slides
Target Audience
*
Medical Professional (Physician, Nurse, Physician Assistant)
Recovery Specialist
Student
Administrator
Criminal Justice Professional
Addictions Counselor
Educator
Other
What is the date of publication?
*
MM slash DD slash YYYY
Provide the link to the product (if there is one):
Collaboration & Targeting
Did you collaborate with another TTC?
*
Yes
No
Please list centers:
*
Which keywords apply to this product/resource?
Mark no more than five:
Adolescents/Youth
African American
Alcohol Misuse/Use
ASAM (patient placement/assessment)
Asian Americans & Pacific Islanders
Binge Drinking
Biology/Neurobiology of Addiction
Clinical Supervision
Co-Occurring Disorders
Community-Based Organizations
COVID-19/Coronavirus
Criminal Justice
Cultural Competency/Humility
Diversity
Domestic Violence
Ethics/HIPAA/Confidentiality
Evidence Based Practices
Faith-Based Initiatives/Spirituality
Fentanyl
Grief
Health Equity
Healthcare
Hepatitis C/HCV
Heroin
Hispanics/Latinos
HIV/AIDS
Homelessness
Implementation Science
Implicit Bias
Integration
Leadership Development
LGBTQ
Marijuana
Men
Mental Health
Motivational Incentives/Motivational Interviewing
Narcan
Native Americans
Older Adults
Opioids
Organizational Change
Outreach Workers
Overdose
Pandemic Response
Pharmacological Interventions/MAT
Pregnancy
Prescription Drugs
Problem Gambling
Recovery Oriented Systems of Care
Recovery Support Services
Recurrence/Recovery Management
Rural Settings
SBIRT
Stigma
Stimulants (Cocaine/Methamphetamine)
Stress
Students/Pre-Service Training
Suicide
Technology Transfer
Telehealth/Tele-Behavioral Health
Tobacco
Training & Skill Development
Trauma
Treatment Planning
Vaping
Veterans
Women
Workforce Development Strategies
Do you want to upload a file?
*
Yes
No
Upload files for this Product/Resource
You can upload multiple files. Files must be under 16MB.
Drop files here or
Select files
Max. file size: 16 MB.
SAMHSA Updates & Website Appearance
Should this product be included in SAMHSA's bi-monthly update? (Product)
*
Yes
No
SAMHSA's Bi-Monthly Report Relation? (Product)
Please check all that apply:
Intensive TA Efforts
Opioid Epidemic
COVID-19
Tribal Communities
N/A
Basic News Info
Title of the News Item
*
Author
Other Author
Article and/or news item content:
*
If there is a link to an external news item, please post that link here.
Link to article
Would you like to upload a file?
*
Yes
No
Upload your file for this News Posting:
You may upload multiple files. Files must be 16MB or smaller.
Max. file size: 64 MB.
In addition to having this information posted to the MPATTC Website, do you need to request anything else be done with the information? Please describe your request here, including as many details as possible. Leave blank if none.
For example, do you need a marketing graphic created, or a Mailchimp template?
Upload any additional documents here:
You may upload multiple documents by continuing to click "select files".
Drop files here or
Select files
Max. file size: 64 MB, Max. files: 6.
Name of Project
Example: Mailchimp Template for Leadership Academy
Please describe the project:
*
Please use this field to describe your request. Include as many details as possible.
Would you like to add a link?
Would you like to add another link?
Would you like to upload a document?
You may upload multiple documents by continuing to click on "Select Files".
Drop files here or
Select files
Max. file size: 64 MB.
Would you like to include anyone else on the communications for this project? You may add up to 3 additional email addresses.
Additional Email 1
Additional Email 2
Additional Email 3