Contact Information

OMB No. 0930-03xx

Expiration Date: xx/xx/2020

Burden Statement: This information is being collected to assist the Substance Abuse and Mental Health Services Administration (SAMHSA) for the purpose of program monitoring of the Technology Transfer Centers (TTC) Network Program. This voluntary information collected will be used at an aggregate level to determine the reach, consistency, and quality of the TTC Program. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. 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 Office of Management and Budget (OMB) control number. The OMB control number for this project is 0930-03xx. Public reporting burden for this collection of information is estimated to average less than 10 minutes per encounter, 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, 5600 Fishers Ln, Room 15 E57B, Rockville, MD 20857.

[Name of Event]

[Date of Event]

[Location of Event]

Because this meeting is federally funded, we have been asked to collect the following information from each participant. All information provided will remain private. Please print responses clearly.

Name: _______________________________

Agency Name and Address: _________________________________________

City: __________________________ State: __________ Zip: ____________

Work Phone: ________________ Work E-mail address: _______________________

Are you willing to be contacted for a brief, Yes

one-month follow-up evaluation of this event? No

If yes, what is your preferred method of contact? E-mail

Mail