Request for T/TA from NRCCPS

				
				

			
				

					
						

						

					
						
Items with an asterisk after the label are required.*


						
						

						

						
						
	
							Request Title*: 
							 


						
 Date Request Received*:
							 

						
						

						State/Tribe/Territory requesting T/TA*:
							
							

							
							

							

						
								Select State/Tribes
								 
								Added State/Tribes
							

							
							

								
								
							
						
								
								
									
										

									
										
								
								
								
								
						
							

							

							
							

							
							
							
						

							
						
						
 Primary Recipient of T/TA:
							 

							
						
						
						
If other than the State/Tribe child welfare agency, specify the primary recipient 
						(e.g, county or local jurisdiction, court, private agencies operating on behalf of the state, etc.)

			
						
						

							

							

								Description of T/TA need*:

								What is the issue you are trying to address?
 What is the history of this issue?		
								
								
								
							
								
							

							

							
							
							
						
						

						
						

						

						

							How the need for T/TA was identified*:  
						
							
							
							
							
						
						

						
						

							 
						

						
						

							if Other, please specify  
							
								
								
							
						
						
						

                        

							 
						

						

						

						
						

						Authorizing Official's Contact Information, if applicable: (e.g. State Level Contact)

							
							

							

								
									Name:
								
								
						
								
								
								
									Email:
								
								
						
								
								
								
									Phone:
								
								
								
								
								
									Extension:
								
								
						
								
							

							
							

								 
								(XXX-XXX-XXXX)
						
								 
							

							
							

							
							
							
						

						
						

						Requestor's Contact Information*:

						
						
							

						
							

								
									Name*:
								
								
						
								
								
								
									Email*:
								
								
						
								
								
								
									Phone*:
								
								
						
								
								
								
									Extension:
								
								
						
								
							

							
							

								 
								(XXX-XXX-XXXX)
								 
							

							
							


						

						

							
							
						
							
							

							

								Organization:   
						
								
								
								
							
						
						
							

							
 

							

								Street:   
						
								
                                	
                                
							

							
 

							
							

								 
								
								
								
						
						
							

							
							
 

							

								City:   
								
								
								
						
									State:    
							
							
							
									Zip:    
								
								
						
								
							

                            

                            	 
                            

							

							
							
								
						

						

						
						

						
						

						Practice Area(s)*:
						
							
							

							
							

							

								Select Practice Area(s)
								 
								Added Practice Area(s)
						
							

							
							

								
							
							
						
							
								
									

									
										
								
							
							
							
						
							

							
							

								 
								if Other, please specify
								
								
								
						
								
							

							

							
							

							
							
							
						

			
						

						Organizational/Systemic Area(s)*:
						
							
							

							

							

								Select Organizational/Systemic Area(s)
						
								 
								Added Organizational/Systemic Area(s)
							

							

								
							
							
						
							
								
									

									
									
										
								
							
							
							
						
							

							
							

								 
								if Other, please specify
								
								
								
						
						
							

							

			
							
							

							
							
							
						

						
						

						Outcomes Targeted*:
						
							
							

							

							

								Select Outcomes Targeted
						
								 
								Added Outcomes Targeted
							

							

								
							
							
						
							
								
									

									
									
										
								
							
							
							
						
							

							
							

								 
								if Other, please specify
								
								
								
						
								
							

							

							
							

							
							
							
						

						
						

						Federal Plan or Review*:
						
							
							

							

							

								Select Federal Plan or Review
						
								 
								Added Federal Plan or Review
							

							

								
							
							
						
							
								
									

									
									
										
								
							
							
							
						
							

							
							

								 
								if Other, please specify
								
								
								
						
								
							

							

							
							

							
							
							
						

						
						

							Optional Field: 
							 

						
						

							Optional Field: 
							 

						
						
						

						List the NRCs that need to be notified of this request:
						
							
							

							

							

								Select NRCs
								 
								Added NRCs