Maternal and Child Health Technical Assistance to State Agencies

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Please complete the following TA Request form.  Upon  completion online, this form will be submitted directly to Roomers, Inc., for approval by Carol O'Toole, Project Officer.  Should you prefer to fax, e-mail, or  mail your TA Request,  please download the PDF or Microsoft Word versions and send to:

 

Roomers, Inc.

803 Cameron Street

Alexandria, VA  22314

(703) 518-0233 phone

(703) 518-0277 fax

mchtaproject@roomersinc.com

 

TA Request Form

Recipient Information
First Name:
Last Name:
Title:
Date:
Agency Name:
Agency Address:
City:
State:
Zip Code:
Telephone:
Fax:
E-mail:
State Contact Person:
Time Requirements for TA:
Identify the Type of TA Requested: Expert Consultant
  State to State (Peer Exchange)
  State Workshop
  Other (Please describe below.)
 

Estimated Costs
Honorarium
A.  Number of Persons Receiving Honorarium:

B.  Number of Days of Honorarium/Person @ $320/day:
Total Honorarium Amount (A) x (B):
Lodging
A.  Number of Rooms Requested:
B.  Lodging Rate/Night:
C.  Number of Nights:
Total Lodging (A) x (B) x (C):
Meals and Incidental Expenses (M&IE)  
A.  Number of Persons Requesting Meals and Incidentals:
B.  Number of Days**:
C.  Meals and Incidental Expenses Rate/Day*:
Total Meals and Incidental Expenses (A) x (B) x (C):
Travel
A.  List Mode of Transportation (i.e., flying, train, etc.):
B.  Number of Persons Flying:
C.  Estimated Airfare/Person:
D.  Local Travel (mileage, cab fare, public transportation):
Total Travel ((B) x (C)) + (D):
Total Estimated TA Expenses:
*Payment for meals and incidental expense (M&IE) will not exceed the official regional government rates found here.
** M&IE for each travel day is calculated at .75 of the 1 day M&IE rate.

Technical Assistance Information
(This section should be filled out prior to the TA.)
Specific Work Areas to be Addressed (please explain):
How would this TA improve your State's Capacity to meet it's priority area?
 
How would this TA help improve your State's Capacity to meet it's Performance Measure Objectives?
 
Desired TA outcomes/objectives:
 
Will a specific product be developed as an outcome of this TA to share with other States? If so, identify the product.
 

 

 

 

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