Technical Assistance Application

Alcohol and Other Drug (AOD) Abuse

Technical Assistance Project

Administered by (Contractor)
For The
California Department of
Alcohol and Drug Programs

* = required field

A. Applicant Information

TA Number:
Contact Person: * Title:
Organization: *
Address: *
City: *
State:* Zipcode:*
County: *
Phone:* Fax:
Email Address: * Website:

B. Organization Description

1. Please check one of the following categories that best describes your organization?

2. How did you hear about our Technical Assistance services? (Please Check One)

3. Please write a brief description of your organization:

4. What is/are your primary funding source(s) for your organization?

C. Technical Assistance Information

1. What kind of assistance is needed? (Check all that apply)
Please Describe:
Identify your primary goal(s) to be achieved through the requested technical assistance or training:
Primary Goal:
Outcome 1:
Outcome 2:
Outcome 3:

2. Describe any previous attempts to address the TA need(s) or obtain consultation or other resources. Also describe the results of those attempts:

3. Proposed training date(s) or timeline:

4. Estimated number of participants:

5. Where will consultation occur?

6. Identify the geographic area(s) to be served by TA or Training service:

7. Please identify the population(s) that will be most impacted by the Technical Assistance or Training services.
Gender
   

Age Group

Ethnicity

8. Does your organization have resources to pay for or share the cost of the technical assistance or training services?
 

9. If yes, please describe the resources your orginization can provide (e.g. funding for consultation fee, photocopy trainning materials, consultant's travel costs, etc.)

10. Are you requesting a specific consultant or consultants?
 
Specified Consultant
If yes, please specify:

Support for this project has been provided by the State of California, Health and Human Services Agency, Department of Alcohol and Drug Programs