Social Work Field Instructor and Nurse Preceptor Program: 
Adolescent SBIRT Track D Online Application
Completing this application signals your interest in accessing FREE training with Continuing Education credits (CEs) on how to conduct adolescent screening, brief intervention, and referral to treatment (SBIRT). This program is designed to prepare social work field instructors (including field supervisors and field directors) and nurse preceptors who supervise students in placement sites.
Click here to continue
 
Instructions for completing this application: Please be prepared to answer all questions in one sitting.  It should take about 5-10 minutes. Once you begin this application you cannot leave and finish later. 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.

For more information about NORC's Adolescent SBIRT Social Work and Nursing Education Project, please visit: http://sbirt.webs.com

For questions, please contact: SBIRTTeam@norc.org

 
How did you hear about this opportunity to participate in the Adolescent SBIRT Social Work Field Instructor and Nurse Preceptor Program (e.g.,  AACN, CSWE, colleague)?

 
Please indicate your role: *


 
Primary Point of Contact: Please enter the contact information for the Social Work Field Instructor or Nurse Preceptor who will serve as the main point of contact for participation in this program?

 
First and Last Name: *

 
Title and Credentials (e.g., Clinical Coordinator, MSN; Field Supervisor, MSW): *

 
Phone number (xxx-xxx-xxxx): *

 
Organization name: *

 
Mailing address: *

 
Please provide a link to your organization's website.

 
Affiliations with Placement Sites: Please list the name(s) of organizations where you serve as a social work field instructor or nurse preceptor? If none, enter N/A. *

 
Affiliations with Academic Programs: Please list the name(s) of any colleges/universities and academic programs with which you are affiliated (e.g., University of ABC, Department of Social Work; ABC College, School of Nursing). If none, enter N/A. *

 
Are you implementing Adolescent SBIRT training/education to staff and/or students at your placement site? *


 
If you are currently implementing adolescent SBIRT training/education at your site, please briefly describe these training activities.

 
Are you currently providing Adolescent SBIRT services to patients/clients at your placement site? *


 
If you are currently providing services, please briefly describe how adolescent SBIRT is implemented in your site. If not, enter N/A.

 
Have you or someone from your organization participated in any of the following activities conducted by NORC's Adolescent SBIRT Project (sbirt.webs.com)? *


 
Program Implementation:  How do you anticipate participating in the training program? *


 
Do you anticipate any challenges with participating in the program? If yes, please briefly explain. If no, please enter None. *

 
Please click the link below and review the Technical Specifications required to run the SBI with Adolescents online simulation training program that will be offered as part of your participation in the Adolescent SBIRT Track D Field Instructor and Preceptor Program

 http://sbirt.webs.com/Track%20D%20Technical%20Specifications.pdf

The technical requirements needed to access the online training are minimal and do not typically require special assistance from IT.

By clicking Yes below, you confirm that you have read the requirements and will have access to a computer that meets the technical specifications. *


 
Thank you for your interest in participating in the Adolescent SBIRT Track D Social Work Field Instructor and Nurse Preceptor 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.

Powered by Typeform