Training and Technical Assistance (TTA) Intake Form Step 1 of 5 20% Name(Required) First Last Pronouns He/Him She/Her They/Them Other Email(Required) Enter Email Confirm Email Address(Required) State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Organization(Required)Job Title(Required) What TTA category does your request fall under?(Required)Select all that apply Consultation Training Webinar Conference Policy Funding Other If other, please specify.(Required)Description of TTA being requested(Required)Briefly, but specifically describe the request.0 of 500 max characters Is this TTA request a training, presentation or conference?(Required) Yes No If yes, please describe and include approximate audience size.(Required)Does this TTA request have an associated event data and time?(Required) Yes No If yes, please include the date.(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920If yes, please include the time.(Required) Hours : Minutes AM PM AM/PM Is this a virtual event or in-person event?(Required) Virtual In-Person Not Applicable If in-person, please indicate the location.(Required) Please list 2-3 goals that you would like to accomplish through this TTA opportunity.(Required)0 of 500 max characters How did you hear about NBHN's TTA offerings?(Required) CDC Office on Smoking and Health CDC Division of Cancer Prevention and Control NBHN Website Social Media Behavioral Health and Wellness Program Smoking Cessation Leadership Program State Tobacco Control Program State Comprehensive Cancer Control Program Other
