Resource Center for Evidence Based Prevention and Intervention Programs

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					  Resource Center for Evidence-Based Prevention and Intervention Programs and Practices
                         Technical Assistance (TA) Request Form
SECTION I – Requester Information
Requesting Agency/Organization:
Requestor’s Name:                                                     Date Request Submitted:
Title:
Address:

Phone:                                                                  Fax:
E:mail:
Date(s) TA is Needed (if time sensitive):
Who is the primary funding source of the program for which you are requesting technical assistance?
   PCCD        PA Dept. of Public Welfare        Medical Assistance       PA Dept. of Health        PA Dept. of Ed
   Federal Grant          Local Sources         Not Currently Funded
Section II (a) Evidence-Based Prevention or Intervention Programs
Orientation for PCCD Supported Evidence-Based Programs (EBPs):
    1. Promoting Alternative Thinking Strategies (PATHS)
    2. Multidimensional Treatment Foster Care (MTFC)
    3. Olweus Bullying Prevention Program (OBPP)
    4. Multisystemic Therapy (MST)
    5. Functional Family Therapy (FFT)
    6. Strengthening Families Program 10-14 (SFP)
    7. The Incredible Years (TIY)
    8. Big Brothers/Big Sisters (BBBS)
    9. Life Skills Training – Middle School (LST)
   10. Project Toward No Drug Abuse (PTNDA)
   Support/Technical Assistance for an EBP not listed above (Specify Program______________________________)
   “Operating an EBP 101” – what you need to know to implement an evidence-based program
   Techniques for Quality Assurance in your EBP
   Data Management Systems – how to establish procedures and protocols for data collection
   Outcome Assessment – measuring the impact of your EBP
   Fidelity Verification – ensuring your EBP is being implemented with fidelity to the model
   Selecting the Right EBP – how to choose the right program based on your community’s risk factors
   Evidence-Based Program CPR – help in revitalizing your EBP
   Marketing your EBP – how to gain community buy-in and support for your prevention/intervention efforts
   Return on Investment Measurement – determining the benefits to the community from the investment in prevention
   Program Evaluation and Performance Measurement Training (Full Day Training)
   Other customized training to meet your specific needs? Go to Section III to provide detail

Section II (b) Communities That Care (CTC)

   Outcome Assessment – measuring the impact of your CTC program on the community
   Choosing an EBP – aid in preparing Risk & Resource Assessments to identify and prioritize risk/protective factors
   Finance Project/Sustainability – locating funding and other support for your CTC
   Strategic Plan Development – long-term planning, setting benchmarks and goals
   CTC Training 1: Community Team Orientation Training
   CTC Training 2: Community Data Collection and Analysis Training
   CTC Training 3: Community Plan and Program Development Training
   CTC Training 4: Implementation and Evaluation
   Prevention Policy Boards (PPBs): Recruiting, Developing and Keeping Boards Alive
   Other customized training to meet specific needs? Go to Section III
Section III– Description of TA Request
Provide concise and complete information in each section below. When completing the form electronically, the size of
each section will increase as needed to accommodate the additional content. If using paper format, add additional pages
as needed.
    1. Statement of Problem:
    Describe, as specifically as possible, the situation or issue for which the training or technical assistance is requested.




    2. Previous Efforts:
    Have there been any previous attempts to address the condition or issue for which technical assistance is requested?
    If so, what action(s) were taken and what were the results?




    3. Training or Technical Assistance:
    Describe, in detail, what type of training or technical assistance you would like to receive.




    4. Target Audience/Recipients:
    List the intended audience/recipients for the training or technical assistance.




    5. Goals and Outcomes:
    Describe what you would like to achieve as a result of this training or technical assistance. Include specifics on
    how this will assist you to address the problem stated above.




      Send your completed form to: wposton@state.pa.us or fax to (717) 772-0551
      For more detailed information on available training and technical assistance go to: www.pccd.state.pa.us and look
                                             under the “Juvenile Justice” link.
       ***Please note that all TA requests will be responded to in the order they are received. If your request is for a
     specific date, your request must be submitted to PCCD/OJJDP for consideration at least 60 days prior to the event.
     Technical Assistance will be provided based upon available resources. Research-Based Delinquency and Violence
         Prevention projects currently funded by PCCD should continue to work directly with the EPISCenter. ***

                          For further information about this form or available services please contact:

                                                         Geoff Kolchin
                                                        Program Analyst
                                     Office of Juvenile Justice and Delinquency Prevention
                                     Pennsylvania Commission on Crime and Delinquency
                                       Phone: (717) 265-8483 or gkolchin@state.pa.us