Adolescent SBIRT Track C: Online Application
Completing this Track C application signals your interest in integrating adolescent SBIRT education into your existing associate, undergraduate, and/or graduate level social work and/or nursing curriculum.
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Instructions for completing this application: Please be prepared to answer all questions in one sitting; once you begin this application you cannot leave and finish later. You can, however, copy and paste answers from a word document into the text fields. Prior to submitting your application, you can go back to any question and modify your answers by scrolling up or down. 

Required questions are indicated with an asterisk (*). Clicking enter will advance you to the next question. In the text fields, press SHIFT+ENTER to add a new paragraph.

When you are ready to submit your application, please proceed to question 18.

For more information on the Adolescent SBIRT Track C program, please visit: http://sbirt.webs.com/rfa-round-2

For questions, please contact SBIRTTeam@norc.org

 
Academic Institution: What is the name of your academic institution, school, department and/or program? *

 
Primary Point of Contact:  What is the contact information for the faculty/educator who will serve as the point of contact for this project?

 
First and Last Name: *

 
Title: *

 
School and Department Name: *

 
Phone: *

 
Mailing Address: *

 
Collaborator Point of Contact:  If there is another school and/or department participating with you, what is the name, title, email address, mailing address, phone number, and school and/or department name for the collaborating point of contact?

 
Current SBIRT Funding:  Are you currently receiving funds from another source to implement SBIRT education into nursing and/or social work education (e.g., SAMHSA, HRSA)? *

     
 
If you answered YES to question #4, that you ARE currently receiving funds from another source, please identify the funding source. If you answered NO to question #4, then enter n/a below. *

 
IRB Application:  Do you anticipate needing to submit an application to your school's Institutional Review Board (IRB) to participate in the Track C RFA program? *

     
 
Participation in the Project:  Have you or someone from your academic institution, participated in any of the following? *


 
Program Level:  In which program level(s) will you implement the Adolescent SBIRT Instructor’s Toolkit materials and/or the SBI with Adolescents simulation program? *


 
Disciplines:  In which discipline(s) will you implement the Adolescent SBIRT Instructor’s Toolkit materials and/or SBI with Adolescents simulation program? *


 
School Term:  In which terms (e.g., semesters or quarters) will you implement the Adolescent SBIRT Curriculum? *


 
Educational Experience: Please describe the educational experience(s) and/or course(s) in which you plan to implement the Adolescent SBIRT curriculum. 

For each educational experience, please note the name and number of course, program level (e.g., BS, MS), setting (in-person, online, hybrid), estimated number of students, estimated implementation term(s) and dates, materials you will use in implementation (Toolkit only, simulation only, or both), and any additional notes. *

Please use this example as a model: Course 1234 - Working with Adolescents: This is an in-person Bachelor's level course with an estimated enrollment of 20 students. The projected implementation term is Spring 2017 and dates are 1/15/17-5/15/17. We will use the SBI Simulation and Toolkit. This course will provide a brief introduction to SBIRT and how to implement it in the field with adolescents. 
 
Implementation Plan for SBI with Adolescents Simulation: If you indicated above that you plan to use the SBI with Adolescents simulation program, please briefly describe how you plan to integrate it into the courses listed above. In your description please specify how the simulation will be assigned and if participation will be mandatory or voluntary.  Please be specific in your description providing the name of the courses if applicable.

If you do not plan to use the SBI with Adolescents simulation please provide a brief explanation as to why your plan does not include it. *

 
Implementation Plan for the Instructor’s Toolkit Materials:  If you indicated above that you plan to use the Instructor’s Toolkit educational materials, please describe how you plan to integrate the materials into the courses listed above (e.g., included as part of in-class instruction prior to assigning the online simulation program; education will be provided to course instructor’s and preceptors prior to implementing education with students). Please be specific in your description providing the name of the courses if applicable.

If you do not plan to use the Instructor’s Toolkit, please provide a brief explanation as to why your plan does not include it. *

 
(OPTIONAL PROGRAM COMPONENT) The Adolescent SBIRT project includes a student evaluation component. The Adolescent SBIRT Team will provide pre- and post- training surveys for use before and after implementing the Toolkit materials and/or simulation progra

 
Are you interested in participating in this evaluation component? *

     
 
If you answered YES to the previous question, what approach or strategies will you use to promote completion of the pre- and post-training surveys?

 
Do you have leadership support to participate in the Track C program (e.g., from the dean, department chair, faculty/colleagues)? *

     
 
Have you already or how will you engage your leadership and others to support its integration into curricula/coursework. (There is no need to include documents of support, please just describe briefly.) *

 
Do you anticipate any challenges with participating in the Track C? If yes, please briefly explain how you’ll work to overcome these challenges. *

 
Please click the link below and review the last page of the document,  Appendix A: Kognito Technical Requirements.

http://sbirt.webs.com/Track%20C%20RFA%20Fall%202016_Application%20Template%20FINAL.pdf

By clicking YES below, you certify that you meet the Minimum Technical Requirements (Technical Specifications) for online simulation training (RFA Appendix A) and confirm your institution complies with the requirements to run the SBI with Adolescents simulation. *


 
Thank you for your interest in participating in the Adolescent SBIRT Track C program.

To submit your application, please click Continue and then click POST YOUR SUGGESTION

A member of the SBIRT Team will contact you within five business days.

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