2014 Nurse-To-Nurse Training Program Application Form

Curry International Tuberculosis Center Tailored TB Training Program 2016 Application

The Tailored TB Training (TTT) program is Curry Center’s effort to bring customized tuberculosis training to nurses, physicians, and allied healthcare workers working in the field throughout the western region of the United State. These trainings can be 4-8 hours in length, and the topic areas will be jointly determined by the hosting jurisdiction and CITC staff. Partnership with local faculty is encouraged, particularly for full-day trainings. We are now accepting applications from jurisdictions within our Western Region service area for a limited number of Tailored TB Trainings to be scheduled in 2016.

Role of the hosting jurisdiction:  Assist in determining training topics/agenda, based on local needs determined by needs assessment activities  Identify local staff to assist in the planning  Assist in recruitment of local TB program staff and/or content experts to serve as faculty  Identify and secure site where training will take place  Market and publicize training to target audience  Provide A/V and other technical support  If possible, provide coffee and/or refreshments on day of training

Role of Curry International Tuberculosis Center:  Coordinate and facilitate planning the training  Assist in development of training agenda  Assist in needs assessment activities to help determine agenda  Create brochure (electronic and/or hard copy) to market training to appropriate learners  Manage registration of participants  Provide access to the materials developed for the training  Provide a CITC faculty/trainer and assist in securing local faculty, as needed  Provide continuing nursing education contact hours (and certificates) and/or continuing medical education contact hours (and certificates) for all eligible participants  Evaluate training and provide summary of feedback to hosting jurisdiction

To apply: 1. Use the application form to provide a written statement indicating why you are interested in hosting a Tailored TB Training in your jurisdiction. 2. Include background information/data on TB training needs of the target audience in your locale. 3. Identify specific topic(s) of interest (e.g., case management, identification and treatment of latent TB infection, TB outbreak management, etc.) and local faculty/trainers who may be willing to serve as faculty for the training. 4. Provide several possible training dates (month/year) that would work for you. 5. All applications will be reviewed by CITC’s Health Education Committee. Applicants will be informed of their application status within 1 month of submitting their application.

of 4 Name: ______Credentials: ______

Position/Title: ______

Institution: ______

Street Address: ______

City: ______State: ______Zip Code: ______

E-Mail: ______

Work phone: ______Cell (optional): ______

The best way to contact me is by:

 E-Mail  Work Phone  Cell Phone

Please indicate why you are interested in hosting a Tailored TB Training in your jurisdiction. ______

What are the specific TB training needs in your locale? How were they assessed? ______Who is the target audience for this training? ______

Please provide any comments or questions you have for us regarding the Tailored TB Training. ______

of 4 What are your preferred date(s) to host a Tailored TB Training? 1st choice: ______2nd choice: ______3rd choice: ______Length of training (minimum of 4 hours to maximum 1 day): ______

Select from the following TB topic areas, the three topics areas of greatest interest to your target audience (with 1 being area of most interest). ______Case management ______Contact investigation/interviewing ______Radiology ______Program management ______Program evaluation ______Infection control; preventing TB transmission ______Identification and management of latent TB infection (LTBI) ______Medical management of tuberculosis ______Management of drug-resistant tuberculosis ______Quality assurance methods for TB control/Cohort review ______Patient education and counseling ______Tuberculin skin testing/IGRAs ______Cultural sensitivity ______Other topic (please specify) ______

Please list any local colleagues that may be available and willing to assist with planning and/or delivering the TTT: ______

Please add any other comments that may be helpful for us as we plan these trainings: ______

of 4 Applicant’s signature: ______Date: ______

Please return the completed form to: Tailored TB Training Curry International Tuberculosis Center, UCSF 300 Frank H. Ogawa Plaza, Suite 520 Oakland, CA 94612-2037 E-Mail: [email protected]