Training Request Form

Name

FirstLast

Your Organization

Address

Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry

Your Role within the Organization

Email

Phone

1. What type of training is needed? Please describe in 100 words or less.

2. Will this training help you achieve any of the following CDC “Public Health Preparedness Capabilities: National Standards for State and Local Planning”? If so, please check the one(s) that relate(s) to your training request: (Optional)

[For more information, see: http://www.cdc.gov/phpr/capabilities/ ]

3. What delivery approach is desired?

Face-to-face (in person, classroom, workshop)
Distance-based technology (video conference, podcast, webcast, etc.)
On-line training module
A combination of delivery modes
Other please describe:

Other:

4. Training Level: At the conclusion of the training, the learner needs to

have a general understanding of the topic.
know and be able to apply content to various situations.
be able to analyze and evaluate information and situations in order to adapt or create plans or response activities.

5. Please describe your primary audience (in terms of profession or job duties) for this training.

6. Has the specific audience you've described above received past training on this subject?

Yes
No
Unsure

If yes, please describe past training:

7. Approximately how many people do you think are likely to participate in this training?

8. Approximately when is this training needed? (Month/year)

9. How was this training need identified? (Check all that apply and describe in 100 words or less)

After-action report (AAR) or improvement plan (IP) following an emergency or disaster
After-action report or improvement plan following an exercise
Other data source following an emergency or disaster
Risk assessment or vulnerability risk assessment
Other means of identifying need

Other:

10. Will staff from your agency provide verbal and written input to help the PERL Center better address training needs?

Yes
No
Unsure at this time

11. Will staff from your agency contribute to the development of evaluation strategies?

Yes
No
Unsure at this time

12. Will staff from your agency share data, including pertinent sections of after-action reports or improvement plans, to assist the PERL Center in evaluating the effectiveness of the training?

Yes
No
Unsure at this time

13. Will staff from your agency help promote the training to encourage participation?

Yes
No
Unsure at this time

14. Please include any additional comments in 100 words or less.

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Training Request Form

[For more information, see: http://www.cdc.gov/phpr/capabilities/ ]

U-SEEE PERL

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U-SEEE PERL Center