Training of Trainers for Peer Programs

New Haven, CT

Monday, November 16 - Thursday, November 19, 2009

Application Form

Background Information
Name:

What type of Ryan White Funding does your agency receive? (check all that apply) Part A Part B Part C Part D AETC None

Job Title:
Organization:
Mailing Address Other Contact Information
Street: Work Phone : Ext.
PO Box: Work Fax:
City: State: Alternate Phone:
Zip Code: Email Address:
Job History and Responsibilities
Length of time in current position: Years of experience in HIV:

Please describe your current job responsibilities:

Please describe your experience working in peer/community health worker/outreach programs:

Have you trained peers or community health workers before? Yes No

If yes, please describe (duration of training, content):

Have you received any training in facilitation skills? Yes No If yes, please described (duration of training, content):

What is your access to the internet? Dial Broadband/High Speed None
Do you have access to a laptop with wireless internet connection that you could bring to a training? Yes No
Needs and Expectations for Course
What organizations will you work with to conduct peer trainings in the next six months?
Name the training partner(s) you have identified to co-facilitate training of peer workers with you .

How many peers to you expect to train in the next six months?

How will these trainings be funded?

Agency Budget Will seek grant funds Registration fees Do not know yet

Please describe the interest and commitment in your community to hire peers who are trained:

What are the demographics and client characteristics of the HIV+ peers in your community?

Are you willing to participate in an evaluation of the workshop program and any training you provide in the 12 months following the workshop? Yes No

What specific knowledge and skills do you hope to learn at this course?

Please specify any special accommodations you may need to attend this course.

Are you able to attend all 4 days of the training (late morning Nov 16 through mid afternoon Nov 19)?

Yes No If no, please explain:

Program Costs

There is no registration fee to participate in this TOT; however, participants will need to pay their own travel to and from the training each day.

Limited scholarship funding is available to pay for hotel accommodation and dinner for participants living 50 miles or more away from the training site. If selected for this scholarship, you will stay at a hotel Monday-Wednesday nights and only have to drive one round trip. Y our name will be given to the hotel as part of the master list of attendees; but to secure your reservation you will need to give the hotel your credit card number in advance. After you are accepted into the TOT and nominated for the scholarship, we will notify you when it is time to contact the hotel and provide them with this information. PACT will then arrange to pay for your hotel bill only. No additional room charges will be paid by PACT.

To request support for travel and or accommodation, please complete the information below.

Name: Organization:

Funds requested for:

Mileage

Lodging

Dinner

Reason for request: