34 - Prof Dev Scholarship Application - M

PROFESSIONAL
DEVELOPMENT
SCHOLARSHIP
APPLICATION

OMB Control Number: 0970-0519
Expiration Date: 05/31/2020

National Human Trafficking Training and Technical Assistance Center
Professional Development Scholarship Application
Thank you for your interest in the Professional Development Scholarship Program. This
application will allow us to learn more about you, your organization, and the event you are
planning to attend. NHTTAC offers the professional development scholarships to individuals
and multidisciplinary teams (MDT) that work with human trafficking survivors and/or
populations at risk of human trafficking. Scholarships are awarded to enhance the
recipient’s ability to deliver a public health response to human trafficking.
The National Human Trafficking Training and Technical Assistance Center (NHTTAC) must
receive the completed Individual or Multidisciplinary Team (MDT) Professional
Development Scholarship application at least 60 calendar days prior to the event or the
request will be rejected - NO EXCEPTIONS. Please note: All MDT members must complete
their own applications and must all be submitted within 48 hours of each other.
For assistance, please contact NHTTAC by calling toll free (844) 648-8822 or emailing
info@nhttac.org

Section A: Applicant Information

This section will provide additional information about you, the applicant.

1. Name of Applicant:
2. Home Address:
3. City
4. Phone:

State:
Fax:

ZIP Code:

Email Address:

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is
to enable NHTTAC to collect recipient and stakeholder feedback to improve NHTTAC’s T/TA service delivery. Public reporting burden
for this collection of information is estimated to average 0.333 hours per respondent, including the time for reviewing instructions,
gathering and maintaining the data needed, and reviewing the collection of information. This collection of information is required to
retain a benefit (22 USC 7104(b) and 7105(c)(4)). An agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid
OMB control number. If you have any comments on this collection of information, please contact the NHTTAC Evaluation Team at
NHTTACEval@icf.com or 9300 Lee Highway, Fairfax, VA 22031.

NHTTAC Professional Development Scholarship Application (Continued)
5.

OMB Control Number: 0970-0519
Expiration Date: 05/31/2020

Individual Application
Multidisciplinary Team Application
o Team Name:
o Team Coordinator:
o Number of Team Members:
o Names of Team Members:






6. How long have you worked with human trafficking survivors and/or populations at risk of
human trafficking? Please specify length of time.
 1-3 years
 3-5 years
 More than 5 years
7. Please provide a detailed description of the direct services you currently provide to
victims of human trafficking and/or populations at risk of human trafficking. (Minimum
of five sentences)

8. Please provide a detailed explanation of how you will use the information you learn to
improve your work with human trafficking and/or populations at risk of human
trafficking. Please provide examples where appropriate. (Minimum of five sentences)

Section B: Organization Information

This section will provide additional information about your organization.

7. Name of Organization:
8. Name and Title of Organization’s Chief Executive:
9. Street Address:
10. City:

11. Phone:

State:

Zip Code:

Fax:

Website:
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NHTTAC Professional Development Scholarship Application (Continued)
12. Applicant’s Position/Title:

OMB Control Number: 0970-0519
Expiration Date: 05/31/2020

13. Type of Organization and/or Role. Select all that apply.
Type of Organization
 Anti-trafficking organization
 Business/for-profit organization
 Coalition/Multidisciplinary Team/Task Force
 Federal government
 Faith-based organization
 State/Local Government






Nonprofit/community-based organization
Survivor led organization
Tribal government
Union/worker advocacy organization
Victim service provider

Professional Capacity and Types of Services
 Behavioral health professional (psychologist, psychiatrist, mental health/substance
use counselor)
 Child welfare (state agency staff; child welfare contractor; non-profit personnel)
 Corrections Based Services
 Criminal justice (e.g., law enforcement, prosecutor, probation, court)
 Educator (teacher, professor, school administrator)
 Health care (physician, physician assistant, nurse practitioner, dentist, nurse,
pharmacist)
 Housing (case worker, shelter director, public housing authority agencies)
 Legal (civil and/or rights-based attorney and/or paralegal, clinic)
 Public health (health department staff, health care executive, community health
workers)
 Social worker (case manager, school counselor, supervisor, administrator)
 Survivor Empowerment and Mentoring
 Other (Specify):
14. Have you or your organization received a NHTTAC Professional Development Scholarship
from in the past 12 months?
Yes

No

Section C: Event Information

This section will provide additional information about the event you are planning to attend.

15. Event Title:
16. Date(s):
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OMB Control Number: 0970-0519
Expiration Date: 05/31/2020

NHTTAC Professional Development Scholarship Application (Continued)
Location (City, State):
17. Name of Organization Sponsoring the Event:
18. Will you be featured as a speaker or trainer at this event?

Yes

No

19. Event Website (If available):

Section D: Budget Information

This section will provide information about your anticipated expenses and expenses to be covered by
your organization.

Applicants are eligible to receive scholarship funds up to $500 for individuals, $1,500 for
multidisciplinary teams. Allowable expenses include tuition/registration fees (late fees are
not allowable), transportation, and lodging. Applicants are eligible to receive up to $500 per
individual recipient for transportation expenses (such as airfare, train, or bus fare), and
lodging expenses (up to the federal government rate in that area, for current rates, please
visit www.gsa.gov). Rental car services are not reimbursable under any circumstances.
Lodging is not covered by the scholarship if the recipient lives within 50 miles of the event.
Expenses will be paid directly on awardees behalf by NHTTAC and our travel agency in
advance of the event. An application missing the following information will be considered
incomplete and rejected. All fields are required; where you are not requesting expense
reimbursements, please enter $0.
Please Note: Scholarship approval is not guaranteed. We advise you not to make any
financial commitment until you receive confirmation from NHTTAC.
A. Expenses

Total

Number of Event Days
Tuition/Registration Fee
No. of Days

Leave Blank

Mode of
Transportation

Leave Blank

Lodging

(Lodging allowance will be calculated by NHTTAC based on per diem rates for
event location.)

Travel (airfare/train/bus) not to exceed $500.

(Travel will be arranged through the NHTTAC travel department. Rental cars are
not allowable under any circumstances)

Please identify which mode of travel is needed for arrival and
departure, and include the dates of travel.
B. Expenses to be Covered by Your Organization

Total
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NHTTAC Professional Development Scholarship Application (Continued)

OMB Control Number: 0970-0519
Expiration Date: 05/31/2020

What other expenses will your organization cover?
(Enter $0 if no funds are available.)

C. Division/Unit/Department’s Budget Information
(Enter $0 for any fields where no funds are available.)

What is your division/unit/department’s current total operating budget?
If $0, please explain here:

What is your division/unit/department’s current training budget?

If $0, please explain here:

How many people does your division/unit/department employ?
Training Budget Comments:

Please use this section to explain items included within the budget figure that might decrease the amount of training
funds allotted to you. Example: if your division/unit/department’s training budget also includes a trainer’s salary, please
mention that here and the amount of the salary.

Section E: Scholarship Concurrence

This ensures that the information provided in Sections A to D, to the best of your knowledge, is
accurate.

I, as the scholarship applicant, certify that:
(1) The information provided in this application is accurate;
(2) I have at least 1 year of experience serving human trafficking survivors and/or
populations at risk of human trafficking;
(3) My organization supports the event and scholarship request, but is unable to
completely underwrite the professional development activity for which I am
requesting support; or I work independently and have attached a letter of support
from someone with whom I have an established working relationship; and
(4) I agree to abide by all requirements noted in this application.
I understand and agree that any false information, misrepresentation, or willful or negligent
failure to disclose any information pertinent to this application or my organization will
constitute sufficient grounds for the removal of my application from consideration, the
return of funding by my organization to the National Human Trafficking Training and
Technical Assistance Center if funding has been granted, and/or disqualification of my
organization from future scholarship opportunities.
Signature of Applicant

Date

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NHTTAC Professional Development Scholarship Application (Continued)

OMB Control Number: 0970-0519
Expiration Date: 05/31/2020

Section F: Supervisor/Chief Executive Attestation

This section ensures that your supervisor or organization’s chief executive supports your attendance at
the training event and all requirements associated with receiving the scholarship. Please note: If you
work independently, you must instead attach a letter of support from someone with whom you have
working relationship.

I support my employee’s Professional Development Scholarship application. I acknowledge
that should a scholarship be awarded, the employee will be permitted to attend the event
and will be supported in the fulfillment of all scholarship requirements. NHTTAC is welcome
to contact me directly to obtain feedback on the impact of the training on my employee’s
ability to provide quality victim services.
Signature of Supervisor

Date

Printed Name of Supervisor
Title of Supervisor
Name of Organization
Phone Number

E-mail Address

Please email the completed application to info@nhttac.org with the subject line stating,
“Professional Development Scholarship Application.”

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is
to enable NHTTAC to collect recipient and stakeholder feedback to improve NHTTAC’s T/TA service delivery. Public reporting burden
for this collection of information is estimated to average 0.333 hours per respondent, including the time for reviewing instructions,
gathering and maintaining the data needed, and reviewing the collection of information. This collection of information is required to
retain a benefit (22 USC 7104(b) and 7105(c)(4)). An agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid
OMB control number. If you have any comments on this collection of information, please contact the NHTTAC Evaluation Team at
NHTTACEval@icf.com or 9300 Lee Highway, Fairfax, VA 22031.

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