Attachment C4 - Contact Information Request Template_FINAL 04.08.20

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Overview

Trainees
Sites

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Sheet 1: Trainees

Attachment C4: Site and Trainee Contact Information Request Template
Health Resources and Services Administration (HRSA) Bureau of Health Workforce (BHW) - Substance Use Disorder Evaluation
Request for Partner Site and Trainee Contact Information
Grantees: Please provide contact information of current trainees. Please do not provide any additional information beyond the fields below. To ensure the secure transfer of contact information, please send this information in a password-protected zip file. Please add more rows as needed.
Grant Program	Training Program Name	Trainee HRSA ID	Trainee First Name	Trainee Last Name	Trainee Title	Trainee Email	Trainee Phone Number	Trainee Mailing Address
E.g., Opioid Workforce Expansion Program	E.g., Mental Health First Aid	123456789	Joe	Smith	Mr.	joe.smith@school.org	123-456-7890	123 First St., Bethesda MD, 20008

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Sheet 2: Sites

Health Resources and Services Administration (HRSA) Bureau of Health Workforce (BHW) - Substance Use Disorder Evaluation
Request for Partner Site and Trainee Contact Information
Grantees: Please provide contact information for point(s) of contact (POC) for partner site(s) that have or have had trainees. Please do not provide any additional information beyond the fields below. To ensure the secure transfer of contact information, please send this information in a password-protected zip file. Please add more rows as needed.
Grant Program	Training Program Name	Site HRSA ID	Site Name	Site POC First Name	Site POC Last Name	Site POC Title	Site PCO Email	Site POC Phone Number	Site POC Mailing Address
E.g., Opioid Workforce Expansion Program	E.g., Mental Health First Aid	123456789	Bethesda Health Clinic	Mary	Lee	Dr.	mary.lee@clinic.org	908-765-54321	123 First St., Bethesda MD, 20008