Great Lakes Trainers Activity Reporting

Form Approved
OMB No. XXXX-XXXX
Exp. Date xx/xx/xxxx

E19. Great Lakes FASD Regional Training Center
Training Activity Reporting Form (TARF) with Process Notes
Name of Individual Submitting Form

Date Form Submitted

TRAINING ACTIVITY
Date of Training:

___________ ___________

Trainer(s): ____________________________

Title of Training:

________________________________________________________________

Completed Pre/Post Evaluations Attached (Y/N):____

Length of Training (minutes:______)

Number of Attendees:_____
ˆ Based on Head Count

ˆ Per Registration List (Attached)

Competencies
Covered

Est. # Minutes Spent
Teaching Competency

I: Foundations of FASD

I # Mins: ________

II: Screening and Brief Interventions

II # Mins: ________

III: Models of Addiction

III # Mins: ________

IV: Biological Effects of Alcohol on the Fetus

IV # Mins: ________

V: Screening, Diagnosis, and Assessment of FAS

V # Mins: ________

VI: Treatment Across the Lifespan for Persons with FASDs

VI # Mins: ________

VII: Ethical, Legal, and Policy Issues

VII # Mins: ________

OTHER

OTHER # Mins: ________

Perception of Audience Receptiveness:

What Went Well?

What Could Be Improved?

Additional Comments (Meaningful Quotation)?

The public reporting burden of this collection of information is estimated to average 2 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. 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. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to - CDC/ATSDR Reports Clearance Officer; 1600 Clifton
Road NE, MS D-74, Atlanta, Georgia 30333 ATTN: PRA (XXXX-XXXX)