OMB Control Number: 0930-0393 Expiration Date: 03/31/2026

SPARK Training and Technical Assistance Request Form
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-0393. Public reporting burden for this collection of information is estimated to average 0.1 hours per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering, and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, samhsapra@samhsa.hhs.gov or 5600 Fishers Lane, Rockville, Maryland, 20857.

The information collected here will be stored in a secure location accessible only by the SPARK Training and Technical Assistance Team. SPARK will use this information to direct you to the appropriate training and technical assistance provider.

I agree that my personal information provided on this form is voluntary and can be used for the purpose(s) mentioned above for SPARK.

Your Name: 	

Your Business Email Address: 	

Date Request Submitted:	

Description of training or technical assistance requested (briefly describe the request. Provide any background information that would be helpful to understand the request):

Goals and Outcomes Expected:

How did you hear about this free TA from SPARK?: 	

Role/Job Title:	

Your Business Phone Number: