EJ TCTAC Technical Assistance Request Form

ICMA EJ TCTAC Technical Assistance Request Form
ICMA is providing free technical assistance to support the environmental justice needs of local and tribal governments and community organizations. To help us understand your needs, please provide us with feedback by filling in and submitting this form. A member of the ICMA TCTAC team will respond as soon as possible. ICMA will use your feedback for internal use only.
Contact Information
Name*

First NameLast Name
Reason for requesting technical assistance. *
Where is your need for technical assistance located?*
Tell us more about where your need for technical assistance is located. (Multiple locations, states or regions)*
Organization/Institution Name *
Email*
example@example.com
Phone Number
Please enter a valid phone number.
Organization Type*

Local GovernmentTribal GovernmentTribal OrganizationNon-Profit/Community-Based OrganizationsPrivate EntityOther
Preferred method of communication.*

PhoneEmailEither is fine
Have you ever administered a federal grant?*

YesNoN/A
How did you hear about our TCTAC?
Have you worked with any of the following entities before?

Other ICMA programsEPA or other federal agencyRegion 1 TCTAC- New England TCTACRegion 2 TCTAC - EAGLERegion 2 TCTAC - WE ACTRegion 3 TCTAC - Mid-AtlanticRegion 4 TCTAC - REACT4EJRegion 4&6 TCTAC - CIRCRegion 5 TCTAC - Blacks in GreenRegion 5 TCTAC - Great LakesRegion 6 TCTAC - South CentralRegion 7 TCTAC - Heartland EJ CenterRegion 8 TCTAC - MaPTCCRegion 9 TCTAC - CCEEJRegion 9 TCTAC - WEST EJ CenterRegion 10 TCTAC - Northwest EJ CenterRegion 10 TCTAC - CEHENational TCTAC - National Indian Health BoardNational TCTAC - Institute for Sustainable CommunitiesOther (listserv, organization, database, etc.)Other
Please verify that you are human :)*
This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-0001, expiration date, July 7, 2027. Responses to this collection of information are voluntary. 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 public reporting and recordkeeping burden for this collection of information is estimated to be 10 minutes per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to Director, Information Engagement Division; U.S. Environmental Protection Agency (2821T); 1200 Pennsylvania Ave., NW; Washington, D.C.20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.
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