Attachment 7 Contact Information Form

Attachment 7 Contact Information Form.doc

National Cross-Site Assessment of Addiction Technology Transfer Centers (ATTC) Network

Attachment 7 Contact Information Form

OMB: 0930-0216

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Attachment 7: Contact Information Form



[Name of Event]

[Date of Event]

[Location of Event]


Because this meeting is federally funded, we have been asked to collect the following information from each participant. All information provided will remain confidential. Please print responses clearly.


Name: _______________________________

Agency Name and Address: _________________________________________

City: __________________________ State: __________ Zip: ____________

Work Phone: ________________ E-mail address: _______________________


Are you willing to be contacted for a brief, Yes

one-month follow-up evaluation of this event? No


If yes, what is your preferred method of contact? E-mail

Mail


File Typeapplication/msword
File TitleExploring Workforce Issues in the
AuthorJennifer Ellingwood
Last Modified Byproth
File Modified2006-11-13
File Created2006-09-28

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