Cross-sector Collaboration Site Visit Opportunity: Justice and Community Partnerships to Address Substance Use

Peer site visit request forms will not be accepted after May 16, 2024. Request forms will be reviewed and approved on a rolling basis, with submissions received by May 2, 2024, receiving priority consideration. Please submit your request by completing this form. A PDF version of the questions is available here. Once you have completed the form and submitted your responses, you will receive a confirmation of receipt. If you have any questions at all, please email COSSUP@iir.com.

APPLICANT INFORMATION

Applicant agency *This question is required.

Applicant jurisdiction (city/county or tribal government entity name and state) *This question is required.

Type of applicant *This question is required.

Please enter an 'other' value for this selection.

PRIMARY CONTACT FOR MATTERS RELATED TO THIS REQUEST

Name *This question is required.

Job Title *This question is required.

Office/agency *This question is required.

Phone Number *This question is required.

Email Address *This question is required. This question requires a valid email address.

Street address *This question is required.

City/State/Zip code *This question is required.

QUESTIONS

What makes now an opportune time to participate in the peer exchange? What interests your team about this opportunity? What do team members hope to learn that would benefit your community in addressing substance use? *This question is required.

One of the goals of this initiative is to support peer learning between the teams that are selected to participate. What could your team contribute to other groups? *This question is required.

MANDATORY TEAM MEMBERS

Applicants must commit to the participation of a diverse group of stakeholders to be considered for this exchange. Selected teams MUST confirm that their attendees can participate in the site visit within 5 days of selection, or an alternate team will be chosen. Selected teams will receive travel scholarships for up to four members, each of whom must be a stakeholder in one of the sectors identified in the Technical Assistance Request Requirements. One additional team member may attend if they can “self-fund” their travel with local dollars.

Mandatory Team Member 1 *This question is required.

Which sector does this team member represent?

A judge or judicial officer who has jurisdiction over child welfare or family court matters
A representative from a child welfare or child-serving agency
A representative from a local law enforcement agency
A representative from the local school system

Name *This question is required.

Job Title *This question is required.

Office/Agency *This question is required.

Phone Number *This question is required.

Email Address *This question is required. This question requires a valid email address.

Mandatory Team Member 2 *This question is required.

Which sector does this team member represent?

A judge or judicial officer who has jurisdiction over child welfare or family court matters
A representative from a child welfare or child-serving agency
A representative from a local law enforcement agency
A representative from the local school system

Name *This question is required.

Job Title *This question is required.

Office/Agency *This question is required.

Phone Number *This question is required.

Email Address *This question is required. This question requires a valid email address.

Mandatory Team Member 3 *This question is required.

Which sector does this team member represent?

A judge or judicial officer who has jurisdiction over child welfare or family court matters
A representative from a child welfare or child-serving agency
A representative from a local law enforcement agency
A representative from the local school system

Name *This question is required.

Job Title *This question is required.

Office/Agency *This question is required.

Phone Number *This question is required.

Email Address *This question is required. This question requires a valid email address.

Optional Team Member 4

Which sector does this team member represent?

A judge or judicial officer who has jurisdiction over child welfare or family court matters
A representative from a child welfare or child-serving agency
A representative from a local law enforcement agency
A representative from the local school system

Name

Job Title

Office/Agency

Phone Number

Email Address This question requires a valid email address.

ADDITIONAL TEAM MEMBER

Each team may send one additional member (for a total of five) if it can support that member’s travel expenses with local funding. Do you intend to send an optional team member? *This question is required.

Additional Team Member

Which sector does this team member represent?

A judge or judicial officer who has jurisdiction over child welfare or family court matters
A representative from a child welfare or child-serving agency
A representative from a local law enforcement agency
A representative from the local school system
Other - Write In

Name

Job Title

Office/Agency

Phone Number

Email Address This question requires a valid email address.

Cross-sector Collaboration Site Visit Opportunity: Justice and Community Partnerships to Address Substance Use

Peer Site Visit Request Form for Montgomery County, Ohio