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Company Name:
Organization Type:
Home
Group Home
Cottages
Residential Placement Agency
Clients Served:
Higher Management
Moderate Management
Low Management
All of the Above
Street Address:
City:
State:
Zip:
Contact Name:
Contact Phone:
Contact E-mail:
Preferred Contact Time:
Time Frame In Which Training Must be Completed:
Group Size:
Participants:
Administrators
Supervisors
Direct Care
Workers
All of the Above
Preferred Training Month:
January
February
March
April
May
June
July
August
September
October
November
December
Preferred Training Region:
North
South
East
West
Evaluate the current performance of the agency that will be trained:
Superior
Above Average
Average
Below Average
Rate the Agency's Top Three Pervasive Needs:
First:
Behavior Management
Inconsistent Program Implementation
Lack of Effective Treatment Methodology
Ineffecitve Training Regiment
Poor Client Outcome
Inability to Track and Interpret Data
Poor Technical Treatment Planning
Other
Second:
Behavior Management
Inconsistent Program Implementation
Lack of Effective Treatment Methodology
Ineffecitve Training Regiment
Poor Client Outcome
Inability to Track and Interpret Data
Poor Technical Treatment Planning
Other
Third:
Behavior Management
Inconsistent Program Implementation
Lack of Effective Treatment Methodology
Ineffecitve Training Regiment
Poor Client Outcome
Inability to Track and Interpret Data
Poor Technical Treatment Planning
Other
Rate Agency's Top Three Strengths:
First:
Flexible System
High Quality Personnel
Setting and Obtaining Systems Goals
Infastructure
Leadership
Fiscal & Material Resources
Long-term Plan
Continuum of Care
Second:
Flexible System
High Quality Personnel
Setting and Obtaining Systems Goals
Infastructure
Leadership
Fiscal & Material Resources
Long-term Plan
Continuum of Care
Third:
Flexible System
High Quality Personnel
Setting and Obtaining Systems Goals
Infastructure
Leadership
Fiscal & Material Resources
Long-term Plan
Continuum of Care
Does the Agency Adhere to any Current Treatment of Staff Training Model?
Yes
No
Title:
Emphasis:
Length of Training:
Agency Population:
Percentage of Students Receiving Free & Reduced Lunch:
Response Based On:
In the Highest Percentile
In the Average Percentile
In the Low Percentile
Data
Emperical Information
Percentage of Students Performing Below Grade Level:
Response Based On:
In the Highest Percentile
In the Average Percentile
In the Low Percentile
Data
Emperical Information
Percentage of Students Receiving Discipline Referrals:
Response Based On:
In the Highest Percentile
In the Average Percentile
In the Low Percentile
Data
Emperical Information
Percentage of Students Identified as Special Education:
Response Based On:
In the Highest Percentile
In the Average Percentile
In the Low Percentile
Data
Emperical Information
Funding for the Training is Provided by:
Federal Grant
State or Local Grant
LEA Funds
State or Local Funds
Other
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