Technical Assistance (TA) Outcome Report For Provider

(Provide the following information for each TA Provided)

* = required field

1. Name / Address / Contact Person of Group Requesting Assistance

Name *
Address *
Contact Person *

2. Name of TA Provider (Contractor or Consultant) *

3. Date(s) TA Provided *

4. Who was Trained (i.e. line staff, manager, board members, etc.)? *

5. Narrative Description of TA Services Provided

A. Background *

B. Description of services provided *

C. Number of Persons and description of target population(s) *

D. Findings/ Outcomes/ Observations *

E. Recommendations *

F. Other

6. Amount of Hours Spent by TA Provider

Preparation *
Travel *
Direct Services (Consultation and/or Training) *
Other (Specify)

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