Master Trainer TA Tracking Form

Form Approved

OMB No. 0920-0941

Exp. Date: 6/30/2015

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Attachment DDDD:

STUDENT CURRICULA 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: (PLEASE CIRCLE ONE) A) Alameda CountY B) Baltimore C) Broward County D) Chicago
2	School NAME:
3	DATE TA REQUEST WAS MADE: (mm/dd/yyyy) _ _ / _ _ / _ _ _ _
4	NAME OF MASTER TRAINER HANDLING TA REQUEST: A) Last Name: _________________ B.)First Name: _________________ C.) Middle Initial __
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 B) PRINCIPAL C) EDUCATOR D) SCHOOL LIAISON FOR DM PROJECT E.) Other: (PLEASE Specify):________________________________)
7	DURING WHAT PHASE OF THE DATING MATTERS INITITATIVE WAS THIS TA REQUEST MADE? (PLEASE CIRCLE ONE) YEAR 1 (2012-2013) B) YEAR 2 (2013-2014) C) YEAR 3 (2014-2015) D) YEAR 4 (2015-2016)
8	TYPE OF TA REQUEST: (PLEASE CIRCLE ONE) INITIAL (NEW) B) FOLLOW-UP (if B selected, please complete B-1) b-1) IF FOLLOW-UP REQUEST, date WHEN WAS THE INITAL REQUEST MADE: (mm/dd/yyyy) _ _ / _ _ / _ _ _ _
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 (PLEASE SPECIFY):_____________________________________

11	HOW DID THE TA REQUESTOR CONTACT YOU? (PLEASE CIRCLE ONE) TELEPHONE B) E-MAIL C) IN-PERSON D) Other (PLEASE SPECIFY): _______________________________________
12	DATE TA WAS PROVIDED IN RESPONSE TO TA REQUEST:
13	HOW WAS THE TA DELIVERED? (PLEASE CIRCLE ONE) A) TELEPHONE B) E-MAIL C) IN-PERSON D) WEBINAR E) Other: (PLEASE SPECIFY):_______________________
14	WHO WERE THE RECIPENTS OF THE TA? (PLEASE CIRCLE ALL THAT APPLY) DM CURRICULA IMPLEMENTER B) PRINCIPAL C) EDUCATOR D) SCHOOL LIAISON FOR DM PROJECT Other: (Please specify) :_______________________________________
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? (PLEASE CIRCLE ONE) A) YES B) NO
19	DID THE NATURE OF THE TA REQUEST REQUIRE YOU TO CONTACT ONE OR MORE OF THE FOLLOWING: (PLEASE CIRCLE ALL THAT APPLY) TA PROVIDER B) SCHOOL LIAISON FOR DM PROJECT C) DM PROGRAM COORDINATOR Other: (Please Specify) :_______________________________________