Form DDDD STUDENT PROGRAM MASTER TRAINER TECHNICAL ASSISTANCE TRAC

Form Approved

OMB No. 0920-XXXX

Exp. Date:

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Attachment DDDD:

STUDENT PROGRAM MASTER TRAINER TECHNICAL ASSISTANCE TRACKING FORM

Dating Matters: Strategies to Promote Healthy Teen Relationships™ Initiative

Division of Violence Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

MASTER TRAINER (MT) TECHNICAL ASSISTANCE TRACKING FORM

No	Questions
1	Dating matters site: Alameda CountY Baltimore Broward County Chicago
2	School NAME:
3	DATE TA REQUEST WAS MADE:_____________________________________
4	NAME OF MASTER TRAINER HANDLING TA REQUEST: ______________________________________
5	ID NUMBER OF MASTER TRAINER HANDLING THE TA REQUEST:_________________________________
6	TA REQUESTOR’S ROLE IN SCHOOL: (PLEASE CIRCLE ALL THAT APPLY) DM CURRICULA IMPLEMENTER PRINCIPAL EDUCATOR SCHOOL LIAISON FOR DM PROJECT DM PROGRAM MANAGER Other: _______________________________________
7	DURING WHAT PHASE OF THE DATING MATTERS INITITATIVE WAS THIS TA REQUEST MADE? YEAR 0 (PLANNING YEAR) YEAR 1 YEAR 2 YEAR 3 YEAR 4
8	TYPE OF TA REQUEST: INITIAL (NEW) FOLLOW-UP IF FOLLOW-UP REQUEST, WHEN WAS THE INITAL REQUEST MADE :_____________________________________
9	THE TA REQUEST WAS RELATED TO WHICH OF THE FOLLOWING STUDENT CURRICULA: (PLEASE CIRCLE ALL THAT APPLY) SAFE DATES (COMPREHENSIVE) SAFE DATES (STANDARD) CDC-DEVELOPED 7TH GRADE CURRICULA CDC-DEVELOPED 6TH GRADE CURRICULA

10

WHAT WAS THE NATURE OF THE TA REQUEST? (PLEASE CIRCLE ALL THAT APPLY) GENERAL IMPLEMENTATION ISSUES CURRICULA DELIVERY ISSUES CURRICULA CONTENT ISSUES SCHEDULING CONFLICTS DISCLOSURE OF SIGNIFICANT EVENTS ISSUES WITH PARTICIPANT RETENTION ISSUES WITH PARTICIPANT ENGAGEMENT STUDENT BEHAVIOR PROBLEMS OTHER:_____________________________________

11	HOW DID THE TA REQUESTOR CONTACT YOU? TELEPHONE E-MAIL IN-PERSON Other: _______________________________________
12	DATE TA WAS PROVIDED IN RESPONSE TO TA REQUEST:______________________________________
13	HOW WAS THE TA DELIVERED? TELEPHONE E-MAIL IN-PERSON WEBINAR Other: _______________________________________
14	WHO WERE THE RECIPENTS OF THE TA (PLEASE CIRCLE ALL THAT APPLY) DM CURRICULA IMPLEMENTER PRINCIPAL EDUCATOR SCHOOL LIAISON FOR DM PROJECT DM PROGRAM MANAGER Other: _______________________________________
15	WHAT WERE THE MASTER TRAINER TA RECOMMENDATIONS?
16	WHAT WERE SOME ACTION STEPS FOR THE TA RECIPENT AS A RESULT OF THE TA PROVIEDED?
17	WHAT WERE SOME ACTION STEPS FOR THE MASTER TRAINER AS A RESULT OF THE TA PROVIDED?
18	WERE THERE PLANS FOR ANY ADDITIONAL FOLLOW-UP? YES NO
19	DID THE NATURE OF THE TA REQUEST REQUIRE YOU TO CONTACT ONE OR MORE OF THE FOLLOWING: (PLEASE CIRCLE ALL THAT APPLY) HAZELDEN TA PROVIDER SCHOOL LIAISON FOR DM PROJECT DM PROGRAM MANAGER Other: _______________________________________