ESC Technical Assistance Submission

ESC Technical Assistance

Use this form to document inquires and technical assistance provided to organizations currently participating in USDA nutrition programs or any non-participating organization seeking program information.
Public table of submission data:

https://www.jotform.com/tables/260226110167142
Organization Served

Identify whether the organization being served is an organization currently participating in a nutrition program or not. After making your selection provide additional identifying information.
Currently ParticipatingNot Participating (NEW)
Participating Organization*
Nonparticipating Organization*
Provide the name of the organization or individual being provided assistance.
Contact Name*

Contact First NameContact Last Name
Title*
Email
example@example.com
Phone Number
Please enter a valid phone number or email above.Format: (000) 000-0000.
Technical Assistance Provided

Identify the programs associated with this assistance request. Provide the time spent on this request, the assistance method, the date provided, and the Rep providing the assistance.
Programs*
SNP
SSO
FFV
SFSP
Centers
DCH
FDP
AtRisk
Other
Time (Hour)*
Enter 0 if < 60 min.
Time (Min)*
Select time in 15 min increments.
Method*
Select the method used to deliver assistance.
Date Provided*

MonthDayYear
ESC Rep*
Select the Representative providing assistance.
ESC Rep Email*
A copy of this submission will be forwarded to the email address provided.
Technical Assistance Description - Areas & Focus

Select one or more categories comprised of an Area & Focus that best describe the nature of the assistance provided. Use the Description text box to provide additional details.
TA Area-Focus*
TA_Area_AdminReview
TA_Area_Applications
TA_Area_Claims
TA_Area_Compliance
TA_Area_Financial
TA_Area_GeneralOps
Description*
Attachments

Add attachments as needed.
Cancelof
CEID
OrgName
Should be Empty:

ESC Technical Assistance

Public table of submission data:

Organization Served

Technical Assistance Provided

Technical Assistance Description - Areas & Focus