Form 1 NRC T/TA Activity

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T/TA Case Number: TA221343

NRC T/TA Activity Form
Definition: T/TA Activity form tracks “Substantial T/TA”--T/TA that requires substantial efforts from the T/TA provider and is tailored to the specific
needs of the State/Tribe. Substantial T/TA is either on-site T/TA (of any duration) or other direct consultation (in-person or remote communication)
totaling at least one hour in a single business day.
Select States/Tribes/Territories

T/TA Recipient*

Added States/Tribes/Territories

AL
AK
AR
CA
CO

Click to ADD >>
<< Click to REMOVE

If other than the State/Tribal child welfare agency,
Prefilled: Able to edit
specify the primary recipient of the approved T/TA
(e.g., county or local jurisdiction, court, private agencies operating on behalf of the state, etc.):
Members of the T/TA Network involved in T/TA Activity
Lead NRC*

Prefilled w/NRC Lead Provider

Select other network members as needed

Added other network members

Nat Res Ctr Org Improvement
Nat Res Ctr Protective Services
Nat Res Ctr Legal & Judical Issues
Nat Res Ctr Welfare Data for Adoption
Nat Res Ctr for Youth Development

NOTE

Click to ADD >>

Only NRCs/Ics
get a tab

<< Click to REMOVE

Save List
NRC1

TTA1

NOTE

TTA2

These tabs are
auto-populated from
the above selection(s)
Start

Type of Entry*

Date(s) of T/TA Activity*

If multi-day, # of on-site days:
Day 1
Hours of contact*

Day 2

days (recorded by ½ day)
Day 3
Day 4

End

mm/dd/yyyy

mm/dd/yyyy

Day 5
Add More Days

Hours of contact delivered in collaboration with Network members
Round to the nearest ½ hour

Mode(s) of contact*

Type of T/TA*

(choose all that apply)

(choose all that apply)

select one

To which mode was the most time devoted?*

Which type of T/TA was most important to this primary mode of delivery?*
T/TA Direct Recipient*

Step in Change Process*

(choose all that apply)

Practice Area(s)*

Prefilled: Able to Edit

(choose all that apply)

NRC/IC Optional Category

select one

Select one

Organizational/Systemic Area(s)*
(choose all that apply)

NRC/IC Optional Category #2

Did any peers (e.g., other States, Tribes, local jurisdictions) participate as providers in this activity?*

Prefilled: Able to Edit
Select all that apply
Yes

No

Peer T/TA Providers
Narrative Description
of Activity

State/Tribal Contact*
Contact Person at T/TA Provider*

Prefilled: Able to Edit

Email*

Phone*

Prefilled: Able to Edit

Email*

Phone*
Cancel

Optional Field:

Save

Optional Field:

NOTE
Modifications can be made to these
tabs. If modifications are present,
when you select “Save” you will
be asked to explain the changes.

NRC TA Activity

3