Parent Program Manager (PPM) Technical Assistance Tracki

Attachment LLLL:

PARENT PROGRAM MANAGER 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

Form Approved

OMB No. 0920-0941

Exp. Date: 06-30-2015

Public reporting burden of this collection of information is estimated to average 10 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0941).

PARENT PROGRAM MANAGER (PPM) TECHNICAL ASSISTANCE TRACKING FORM

Site Number:

School Number:

School Name:

Program Year:

No	QUESTIONS
1	Dating matters site: (PLEASE CIRCLE ONE) A) Alameda CountY B) Baltimore C) Broward County D) Chicago
2	DATE TA REQUEST WAS MADE: (mm/dd/yyyy) _ _/_ _/_ _ _ _
3	PARENT PROGRAM MANAGER NAME HANDLING TA REQUEST: A) Last Name: _______________ B.)First Name: ______________ C.) Middle Initial: _
4	PARENT PROGRAM MANAGER ID NUMBER HANDLING THE TA REQUEST: _ _ _ _ _ _
5	PARENT FACILITATOR NAME REQUESTING TA: A) Last Name: _______________ B.)First Name: ________________ C.) Middle Initial: _
6	PARENT FACILITATOR ID NUMBER REQUESTING TA: _ _ _ _ _ _
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) A) INITIAL (NEW) B) FOLLOW-UP (if B selected, please complete B-1) B-1) IF FOLLOW-UP REQUEST, WHEN WAS THE INITAL REQUEST MADE (pLEASE SPECIFY DATE): (mm/dd/yyyy) _ _/ _ _/ _ _ _ _
9	THE TA REQUEST WAS RELATED TO WHICH OF THE FOLLOWING PARENT CURRICULA: (PLEASE CIRCLE ALL THAT APPLY) A) FAMILIES FOR SAFE DATES (8TH GRADE PARENT CURRICULA) B) DATING MATTERS FOR PARENTS (7TH GRADE PARENT CURRICULA) C) PARENTS MATTER! FOR DATING MATTERS (6TH GRADE PARENT 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 OTHER (PLEASE SPECIFY):_____________________________________

11	HOW DID THE PARENT FACILITATOR CONTACT YOU? (PLEASE CIRCLE ALL THAT APPLY) TELEPHONE B) E-MAIL C) IN-PERSON D) Other (Please Specify): _______________________________________
12	DATE TA WAS PROVIDED IN RESPONSE TO TA REQUEST: (mm/dd/yyyy) _ _/_ _/_ _ _ _
13	HOW WAS THE TA DELIVERED? (PLEASE CIRCLE ALL THAT APPLY) TELEPHONE B) E-MAIL C) IN-PERSON E) WEBINAR F) Other (PLEASE SPECIFY):_____________________________
14	WHAT WERE THE PARENT PROGRAM MANAGER TA RECOMMENDATIONS?
No	QUESTIONS
15	WHAT WERE SOME ACTION STEPS FOR THE PARENT FACILITATOR AS A RESULT OF THE TA PROVIEDED?
16	WHAT WERE SOME ACTION STEPS FOR THE PARENT PROGRAM MANAGER AS A RESULT OF THE TA PROVIDED?
17	WERE THERE PLANS FOR ANY ADDITIONAL FOLLOW-UP? (PLEASE CIRCLE ONE) YES B) NO
18	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) DM PROGRAM MANAGER C) CDC D) Other (PLEASE SPECIFY): __________________________________