HAVI Training & Technical Assistance Request Form

You will receive Violence is Preventable: A Best Practices Guide for Launching & Sustaining a Hospital-based Program to Break the Cycle of Violence in an email when you submit this form.

If there is additional information you’d like, specify here:

Would you like to schedule a meeting with the HAVI at this time to answer any general questions?*

Yes, pleaseNo, thank you

Do you currently have a HVIP?*

YesNo

Are you a current member?*

YesNo

If you are a member, please select your program name.*

What type of program is your HVIP?*

Hospital Based (program staff are employees of the hospital)Hospital linked (program staff are employees of a community-based organization that has an MOU with the hospital to provide services)Hybrid (Combination of program staff are employees of the hospital and community-based organization)

When did your program start?*

Are you currently seeing clients?*

YesNo

How long has your program been seeing clients?*

Are you hoping to start a HVIP within the next year?*

YesMaybe/HopefullyNot the next year, but sometime in the futureNo

Do you currently have funding for training and technical assistance?*

YesNo

Violence Prevention Professional (VPP) Training is the Health Alliance for Violence Intervention’s national training program for frontline violence intervention workers.

Are you interested in receiving VPP training for yourself or frontline violence intervention workers at your program?

YesNoMaybeWhat is the VPP Training?

For more information on our VPP Training, please visit this page on our website.

Are you interested in receiving more information about trainings and webinars?*

YesNoMaybe

Please let us know which content areas are you interested in receiving a training*

	Yes, please	No, Thank you	Possibly, I'm not sure.
HVIP Planning and Design
Participant Engagement
Staff Development
Strategic Partnerships
Data Collection and Evaluation

If there’s additional trainings or webinars you’d like to receive, describe them below:

If there are specific things you'd like to discuss with the HAVI, please type them here.

Please give a detailed description of the Training & Technical Assistance that you're requesting. *

Upload documents/proposals that you would like for us to review prior to our first meeting.

Would you like to be added to the HAVI newsletter to receive regular updates from the HAVI?*

Yes, subscribe me to the HAVI newsletter.No, thank you.

When you click submit, your information will be shared with our Business Development team. If you requested a meeting, we will reach out to you to schedule a time to discuss your needs.

HAVI Training & Technical Assistance Request Form

General HVIP Information

Other

Program Consultation