Form Event Description Event Description Event Description Form

Event Code ________________

A

Form Approved

OMB No.: 0930-0216

Exp. Date 02/28/2013

See burden statement on next page

TTC Event Description Form

Please complete this form for each event implemented or sponsored by your ATTC.

Date: ___________________ Location: ________________ ATTC:_____________

Event Title: _____________ ______________ Event Code No.: ___________________

Co-sponsors: ______________________________________________________________

Total # of participants: ________ Total # of PREs collected: _________

# of participants consenting to follow-up: _________ Total # of Follow-up surveys sent: _____

A> TAP 21. Check all the TAP 21 competency areas that apply to this event:

____ 1 Transdisciplinary Foundations ____ 2.5 Counseling

____ 2.1 Clinical Evaluation ____ 2.6 Client, Family & Community Education

____ 2.2 Treatment Planning ____ 2.7 Documentation

____ 2.3 Referral ____ 2.8 Professional and Ethical Responsibilities

____ 2.4 Service Coordination

B1>SAMHSA Programs/Issues and other Special Topics. Is the event intended to focus on any of the following special topics? Check all that apply:

____ Co-occurring Disorders ____ Substance Abuse Treatment Capacity

____ Seclusion & Restraint ____ Strategic Prevention Framework

____ Children & Families

____ Mental Health Systems Transformation____ Suicide Prevention

____ Homelessness ____ Older Adults

____ HIV/AIDS/Hepatitis ____ Criminal & Juvenile Justice

____ Workforce Development

B2>SAMHSA Cross-Cutting Principles. Check all that apply:

____ Science to Services/Evidence-Based ____ Data for Performance Measurement &

Practices Management

____ Collaboration w/ Public & Private ____ Reducing Stigma & Barriers to Service

Partners

____ Cultural Competency/Eliminating ____ Community & Faith-Based Approaches

Disparities

____ Trauma & Violence ____ Financing Strategies/Cost-effectiveness

____ Rural & Other Specific Settings ____ Disaster Readiness & Response

C> Contact Hours How many contact hours is this event? _________________

NOTE: For academic credit-hour courses, multiply the number of credit hours assigned by 15 to calculate contact hours (e.g. 3 credit hours x 15 = 45 contact hours)

D> Is this a Training of Trainers (TOT) Event? ___ Yes ___ No

E> Event Format and Technology Characteristics

• Which of the following best describes the event?:

__ Workshop __Instit./Conf. ___Univ./College Course ___Comm. Coll. Course

__ Technical Assistance ___ Meeting

• Does the event occur in:

___ a concentrated period (e.g. one or more consecutive days) or

___ spread out over a length of time (e.g. a semester course)

• Technology Format: (Select one)

______ Traditional Classroom Format

______ Practicum/Internship Experience

______ Distance Learning Format (Please specify):

______ Ground Mail Format

______ E-mail Format

______ On-line/ Web-based Format

______ Tele-video Format

______ Other; Please indicate: ______________________________________

Publication Use. Please record the TIPs, TAPs and other publications you used in this event.

The publications I used in this event were:

TIP #	USE	TAP#	USE
1: State Methadone Tx Guidelines		1: Approaches in Treat. of Adolescent
2: Pregnant, SA Women		2: Medicaid Financing
3: Screen and Assess Adolescents		3: Need, Demand, and Problem Asses.
4: Guidelines for Adolescents		4: Coordination of ADM Services
5: Drug Exposed Infants		5: Self-Run, Self-Supported Houses
6: Screening Infectious Diseases		6: Empowering Families
7: Screening & Assess in CJ		7: Methadone
8: Intensive Outpatient Tx		8: Relapse Prevention
9: Coexisting MI and SA		9: Funding Resource Guide
10: Cocaine and Methadone		10: Rural Issues
11: Simple Screening for Outreach		11: Opportunities for Coordination
12: Intermediate Sanctions		12: Narcotic Treatment Programs
13: Patient Placement Criteria		13: Confidentiality
14: State Outcomes Monitoring		14: Siting D and A Treatment Prog.
15: HIV-Infected Abusers		15: Forecasting Cost in Managed Care
16: Trauma Patients		16: Purchasing Managed Care Svcs.
17: Adults in Criminal Justice Sys		17: Rural and Frontier Treatment
18: Tuberculosis Epidemic		18: Confidentiality Compliance
19: Detoxification		19: Relapse Prevention for Offenders
20: Opioid Substitution Therapy		20: Excellence to Rural and Frontier
21: Diversion for Juveniles		21: Addiction Couns Competencies
22: LAAM of Opiate Addictions		21A: Clinical Supervision Comps
23: Drug Courts		22: Contracting for Services
24: Primary Care Clinicians		23: Women Offenders
25: Domestic Violence		24: Welfare Reform & Confidentiality
26: Older Adults		25: Impact of SA Tx on Employment
27: Comprehensive Case Manage		26: ID SA among TANF-elig Families
28: Naltrexone		27: Linking A&D Svcs. w/ Ch Welfare
29: Phys & Cognitive Disabilities		28: NRADAN Awards for Excellence
30: Continuity of Offender Treat		29: State Admin Records for Perf. Mgt
31: Screening Adolescents		30: Buprenorphine for Nurses
32: Treatment of Adolescents		31: Implementing Change
33: Tx for Stimulant Use Disorders
34: Brief Interventions & Therapies		Other Publications	USE
35: Enhancing Motivation		The Change Book
36: Child Abuse & Neglect Issues		Specify Other Titles:
37: SA Tx and HIV/AIDS
38: SA Tx and Vocational Svcs.
39: SA Tx and Family Therapy
40: Buprenorphene & Opioid Tx
41: SA Tx: Group Therapy
42: SA Tx for Co-occur. Disorders
43: Med-assted Tx for Opioid Addic
44: SA Tx in the CJ System
45: Detox and SA Tx
46: Admin Issues – Intensive Outpt.
47: Clinical Issues – Intensive Outp.
48: Managing Depressive Symptom
49: Inc. Alco. Pharm. Into Med Prac.
50: Addressing Suicidal Th./Behav.

Public reporting burden for this collection of information is estimated to average 15 minutes per response to complete the Contact Information Form and this questionnaire. Send comments regarding this burden estimate or any other aspect of this collection of information to the SAMHSA Reports Clearance Officer, Room 16-105, 5600 Fishers Lane, Rockville, MD 20857. 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. The control number for this project is 0930-0216.

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