Name Credentials (example: RN, BS, MPH, MD, PhD) Position/Title Institution Street Address City State - Select -AlaskaArizonaCaliforniaColoradoHawaiiIdahoMontanaNevadaNew MexicoOregonUtahWashingtonWyomingthe U.S. Pacific Island Territories Zip Code E-Mail Work Phone Cell Phone (optional) The best way to contact me E-Mail Work Phne Cell Phone Please indicate why you are interested in hosting a Tailored TB Training in your jurisdiction What are the specific TB training needs in your locale? How were they assessed? Who is the target audience for this training? Please provide any comments or questions you have for us regarding the Tailored TB Training. Date preferences: Curry Center will try to accommodate your date preferences. However, confirmation is subject to availability. Length of training (minimum of 4 hours to maximum 1 day) 1st Choice Date 2nd Choice Date 3rd Choice Date Select from the following TB topic areas, the three topic areas of greatest interest to your target audience. 1st Topic Choice - Select -Case managementContact InvestigationRadiologyProgram managementProgram evaluationInfection control;preventing TB transmissionIdentification and management of tuberculosisMedical management of tuberculosisQuality assurance methods for TB control/Cohort reviewPatient education and counselingTuberculin skin testing/IGRAsCultural sensitivityOther 2nd Topic Choice - None -Case managementContact InvestigationRadiologyProgram managementProgram evaluationInfection control;preventing TB transmissionIdentification and management of tuberculosisMedical management of tuberculosisQuality assurance methods for TB control/Cohort reviewPatient education and counselingTuberculin skin testing/IGRAsCultural sensitivityOther 3rd Topic Choice - None -Case managementContact InvestigationRadiologyProgram managementProgram evaluationInfection control;preventing TB transmissionIdentification and management of tuberculosisMedical management of tuberculosisQuality assurance methods for TB control/Cohort reviewPatient education and counselingTuberculin skin testing/IGRAsCultural sensitivityOther Please specify other topic(s) Please list any local colleagues that may be available and willing to assist with planning and/or delivering the TTT Please add any questions or comments that may be helpful for us as we plan these trainings.