Nevada Opioid Center of Excellence (NOCE): Training & Technical Assistance (T&TA) Requests Form - The Nevada Opioid Center of Excellence (NOCE)

Contact Information

Please provide contact information for the person who will be responsible for this request.

Name(Required)

First Last

Role/Job Title(Required)

Email Address(Required)

Work Phone(Required)

Cell Phone (if applicable)

Organization(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Description of TA Requested

The Nevada Opioid Center of Excellence (NOCE) provides free education and training in the state of Nevada. Please describe the education and/or training goals of the request. Provide any background information or context that you think would be helpful in understanding the request. (Note: A Technology Transfer Specialist will be in touch with you to get the details of the request)

Describe your training and/or technical assistance needs:(Required)

Brief description of services provided by your agency/organization(Required)

Requested delivery method of T&TA (select delivery method):(Required)

Virtual Webinar/Meeting

Onsite/In-person

Other

If in-person, proposed Location of training:(Required)

Requested date of T&TA:

Month

Day

Year

Estimated Number of Participants

Will the training be open to the public?(Required)

Yes

Continuing Education Credit requested?(Required)

Yes

Demographics Information

Are you a current grantee or recipient of any opioid-funding?(Required)

Yes

Please note that an affiliation is not necessary to receive Nevada Opioid Center of Excellence (NOCE) services.

If yes, please specify:(Required)

Fund for Resilient Nevada (FRN)

State Opioid Response (SOR)

Overdose to Action (OD2A)

Other, please specify:

Other, please specify:(Required)

How did you hear about this Technical Assistance (TA) opportunity with the Nevada Opioid Center of Excellence (NOCE)?(Required)

Attended a training, event, or presentation/speech where the Nevada Opioid Center of Excellence (NOCE) was mentioned

Listserv announcement

Colleague recommended

Exhibit at a conference or meeting

Online search

Social media

Other

Please choose the single option that matches most closely, or choose "Other"

Are you making this request on behalf of a Tribe or organization with a Tribal focus?(Required)

Yes

Additional Questions/Comments: