Form Training Sign-in S Training Sign-in S Training Sign-in Sheet

Form Approved

OMB No._ 0930-0276 _

Exp. Date:xx-xx-xxxx

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is_____. Public reporting burden for this collection of information is estimated to average __ minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

TRAINING SIGN-IN SHEET

Title of Training: ______________________________________________________________________________

Date(s) of Training: ________________________________________________________________________

The Center for Mental Health Services in the Substance Abuse and Mental Health Services Administration (SAMHSA) of the United States Department of Health and Human Services is sponsoring a national evaluation of the National Child Traumatic Stress Initiative (NCTSI), which includes the National Child Traumatic Stress Network (NCTSN). You are invited to participate in this evaluation because you are receiving training from a Federally funded NCTSN center.

Your input is important in improving understanding of how the NCTSN is working to provide trauma-related training to human service providers across services disciplines throughout the country. Human service providers include a wide range of community-based professionals who interact frequently with children and engage in multiple activities, from prevention to screening, early identification, and the provision of clinical interventions; such providers may include mental health professionals, teachers, child welfare staff, juvenile justice staff, health care providers and first responders.

These same questions are being asked of other training participants. Completing the survey will take about 10 minutes. Upon completion of the survey, you will have the opportunity to register to participate in a lottery to win a $50 gift certificate to thank you for your time and attention to this important matter. If you are willing to be contacted for this survey, please indicate with a check mark in the last column.

Participant Name	Organization/ Employer	Professional Role	E-mail	Willing to Participate in Survey
Participant Name	Organization/ Employer	Professional Role	E-mail	Willing to Participate in Survey

Training Sign-In Sheet 2