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Great Lakes FASD Regional Training Center - Training Activity Request and Planning Form

* Required Field

Contact Information (training materials will be sent to this address)

*Trainer *Date
*Mailing Address
*City
State
Zip
*Phone
*Email
Presentation (P)
(Post-Eval Only) 		Skills-Building Training (S)
(Pre-/Post-Eval & F-Up)		 Information Sharing ( I )
(No Evaluations)


Is this part of a larger conference or training? No Yes (specify)
Presentation Title:
Other Trainer(s):
Number of Participants:
Training Dates:
Training Location:
Address
City
State
Zip
Do you want this training
listed on this website?		 Yes   No
Other Training Requests/Issues
POWERPOINT PRESENTATION (PPT):
PPT Previously Approved Using CDC/GLFRTC Master PPT
New PPT Submitted Non PPT Materials Submitted


List Specific Training Goals and Anticipated Outcomes
Audience Competency(ies) Covered Time Spent on Topic
Physicians
Nurses (NP, RN, LPN)
Physicians Assistants
Mental Health Providers (Psychologists,
Counselors, Social Workers)
OT/PT/SLP
Other Health Professionals
Other Allied Health Professionals
Other Professional (specify):

Students (specify fields):

Educators		 I: Foundations of FASD
II: Screening and Brief Interventions
III: Models of Addiction
IV: Biological Effects of Alcohol on Fetus
V: Screening, Diagnosis, and Assessment of FAS
VI: Treatment Across the Lifespan
VII: Ethical, Legal, and Policy Issues

Other Requested Topics (specify):
I # Mins:
II # Mins:
III # Mins:
IV # Mins:
V # Mins:
VI # Mins:
VII # Mins:


Other # Mins:

Total Minutes:



Continuing Education Units (CEUs)
Are you requesting continuing education units?
 If yes, please submit CEU request form.		 Yes   No
Are you providing other credit, certification, etc.? Yes   No
If yes, please specify:

1100 Delaplaine Court | Madison, WI 53715 | 608-263-5613 | 1-800-752-3157 | Email Us

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Funding provided by the Department of Health and Human Services, Centers for Disease Control and Prevention

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