Form Approved 

OMB No.: 0930-0216 

Exp. Date 01/31/2014 

See burden statement on last page 

Addiction Technology Transfer Center (ATTC) Event Description Form 

Please complete this form for each event implemented or sponsored by your ATTC. 

Date: _ ______ Location: _ ATTC:_____________ 

Event Title: _____________ ______________ Event Code No.: __ __________ 

Co-sponsors: ______________________________________________________________ 

Total # of participants: ________ Total # of PREs collected: _________ 

# of participants consenting to follow-up: _________ Total # of Follow-up surveys sent: _____
 

A> TAP 21. Check all the TAP 21 competency areas that apply to this event: 

____ 1 Transdisciplinary Foundations ____ 2.5 Counseling 

____ 2.1 Clinical Evaluation ____ 2.6 Clients, Family & Community Education 

____ 2.2 Treatment Planning ____ 2.7 Documentation 

____ 2.3 Referral ____ 2.8 Professional and Ethical Responsibilities 

____ 2.4 Service Coordination 

B1>SAMHSA Programs/Issues and other Special Topics. Is the event intended to focus on any 

of the following special topics? Check all that apply: 

____ Co-occurring Disorders ____ Substance Abuse Treatment Capacity 

____ Seclusion & Restraint ____ Strategic Prevention Framework 

____ Children & Families 

____ Mental Health Systems Transformation____ Suicide Prevention 

____ Homelessness ____ Older Adults 

____ HIV/AIDS/Hepatitis ____ Criminal & Juvenile Justice 

____ Workforce Development 

B2>SAMHSA Cross-Cutting Principles. Check all that apply: 

____ Science to Services/Evidence-Based ____ Data for Performance Measurement & 

Practices Management 

____ Collaboration w/ Public & Private ____ Reducing Stigma & Barriers to Service 

Partners 

____ Cultural Competency/Eliminating ____ Community & Faith-Based Approaches 

Disparities 

____ Trauma & Violence ____ Financing Strategies/Cost-effectiveness 

____ Rural & Other Specific Settings ____ Disaster Readiness & Response 

C> Contact Hours How many contact hours is this event? _________________ 

NOTE: For academic credit-hour courses, multiply the number of credit hours assigned by 15 

to calculate contact hours (e.g. 3 credit hours x 15 = 45 contact hours) 

D> Is this a Training of Trainers (TOT) Event? ___ Yes ___ No 

E> Event Format and Technology Characteristics 

	 Which of the following best describes the event?: 

__ Workshop __Instit./Conf. ___Univ./College Course ___Comm. Coll. Course 

__ Technical Assistance ___ Meeting 

Revised: 6/3/2010 Page 1 of 3 v2.1 
 

Event Code ________________ 

 Does the event occur in: 

___ a concentrated period (e.g. one or more consecutive days) or 

___ spread out over a length of time (e.g. a semester course) 

	 Technology Format: (Select one) 

______ Traditional Classroom Format 

______ Practicum/Internship Experience 

______ Distance Learning Format (Please specify): 

______ Ground Mail Format
 

______ E-mail Format 

______ On-line/ Web-based Format 

______ Tele-video Format 

______ Other; Please indicate: ______________________________________ 

Revised 6/3/2010 Page 2 of 3 v2.1 
 

 

 

 

Event Code ________________ 

Publication Use. Please record the TIPs, TAPs and other publications you used in this event. 

The publications I used in this event were: 

TIP # USE TAP# USE 

1: State Methadone Tx Guidelines 1: Approaches in Treat. of Adolescent 

2: Pregnant, SA Women 2: Medicaid Financing 

3: Screen and Assess Adolescents 3: Need, Demand, and Problem Assess. 

4: Guidelines for Adolescents 4: Coordination of ADM Services 

5: Drug Exposed Infants 5: Self-Run, Self-Supported Houses 

6: Screening Infectious Diseases 6: Empowering Families 

7: Screening & Assess in CJ 7: Methadone 

8: Intensive Outpatient Tx 8: Relapse Prevention 

9: Coexisting MI and SA 9: Funding Resource Guide 

10: Cocaine and Methadone 10: Rural Issues 

11: Simple Screening for Outreach 11: Opportunities for Coordination 

12: Intermediate Sanctions 12: Narcotic Treatment Programs 

13: Patient Placement Criteria 13: Confidentiality 

14: State Outcomes Monitoring 14: Sitting D and A Treatment Prog. 

15: HIV-Infected Abusers 15: Forecasting Cost in Managed Care 

16: Trauma Patients 16: Purchasing Managed Care Svcs. 

17: Adults in Criminal Justice Sys 17: Rural and Frontier Treatment 

18: Tuberculosis Epidemic 18: Confidentiality Compliance 

19: Detoxification 19: Relapse Prevention for Offenders 

20: Opioid Substitution Therapy 20: Excellence to Rural and Frontier 

21: Diversion for Juveniles 21: Addiction Couns Competencies 

22: LAAM of Opiate Addictions 21A: Clinical Supervision Comps 

23: Drug Courts 22: Contracting for Services 

24: Primary Care Clinicians 23: Women Offenders 

25: Domestic Violence 24: Welfare Reform & Confidentiality 

26: Older Adults 25: Impact of SA Tx on Employment 

27: Comprehensive Case Manage 26: ID SA among TANF-elig Families 

28: Naltrexone 27: Linking A&D Svcs. w/ Ch Welfare 

29: Phys & Cognitive Disabilities 28: NRADAN Awards for Excellence 

30: Continuity of Offender Treat 29: State Admin Records for Perf. Mgt 

31: Screening Adolescents 30: Buprenorphine for Nurses 

32: Treatment of Adolescents 31: Implementing Change 

33: Tx for Stimulant Use Disorders 

34: Brief Interventions & Therapies Other Publications USE 

35: Enhancing Motivation The Change Book 

36: Child Abuse & Neglect Issues Specify Other Titles: 

37: SA Tx and HIV/AIDS 

38: SA Tx and Vocational Svcs. 

39: SA Tx and Family Therapy 

40: Buprenorphene & Opioid Tx 

41: SA Tx: Group Therapy 

42: SA Tx for Co-occur. Disorders 

43: Med-Assted Tx for Opioid Addic 

44: SA Tx in the CJ System 

45: Detox and SA Tx 

46: Admin Issues – Intensive Outpt. 

47: Clinical Issues – Intensive Outpt. 

48: Managing Depressive Symptom 

49: Inc. Alco. Pharm. Into Med Prac. 

50: Addressing Suicidal Th./Behav. 

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for completing 

this questionnaire. Send comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA 

Reports Clearance Officer, Room 7-1044, 1 Choke Cherry Road, Rockville, MD 20857. An agency may not conduct or sponsor and a 

person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The control 

number for this project is 0930-0216. 

Revised 6/3/2010 Page 3 of 3 v2.1