ORGANIZATION COMMITMENT FORM

Ohio Disability and Health Program

LIFT: Living Independently from Tobacco Train-the-Trainer Workshop

Columbus, Ohio

Applications must be received prior to workshop start date.

Background information: The purpose of this project isto increase the number of LIFT Trainers in Ohio in order to positively impact the quality of life of Ohioans with developmental disabilities. The project is offering training and certification to providers serving people with intellectual and/or developmental disabilities (IDD). Selected participants will be trained on the LIFTCurriculum and will implement the program within their respective organizations.To learn more about the LIFT curriculum visit: enter “LIFT”in the search box.

The sponsors of this project, Ohio Disability and Health Program (ODHP), receive federal funding and are required to show the impact they have in improving people with disabilities’ quality of life and inclusion in the community. The impact is demonstrated by sharing the LIFT data that is collected by LIFT Trainers as part of theLIFT workshops, with the funding agencies. Therefore, it is very important that certified LIFTTrainers collect the data on how many people with disabilities participated in LIFT workshops,what they gained from it and how it improved their health and quality of life.

Your role: If you choose to apply and your organization is selected to participate, the Ohio Disability and Health Program(ODHP) will ask that you agree to complete the following tasks:

  • Send one or two people from your organization to the Train-the-Trainer (T-the-T) workshop to be trained on the Living Independent from Tobacco (LIFT)curriculum and become a certified LIFT Trainer. The workshop participant(s) should fall into one or more categories within their respective organizations: Program manager, site coordinator, or designated training specialist who wishes to become a certified trainer within the organization.
  • After completing the T-the-T workshop, each participant will be expected to implement the curriculum within their respective organizations; within one year following the training. Sites will be asked to:
  • Conduct the workshop.
  • Track and report the number of workshops and participants who have successfully completed the workshops to be shared with ODHP team members.

Risks: We don’t know of any risks in participating in this project.

Benefits: If your organization is selected to participate in the project, you will have:

  • A chance to participate in a T-the-T workshop to train on an exciting, tobacco cessation program specifically developed for people with disabilities;
  • A chance to introduce and implement the curriculum in your organization;
  • The opportunity to become a certified trainer on a federally recognized evidence-based health promotion curriculum.

Compensation: Selected participants will partake in a T-the-T workshop on the curriculum at no charge. Workshop participants will receive a curriculum (training guide) to use when delivering their workshops.

Contacts and Questions: Please contact Erica Coleman with any questions: 513-803-4399 or

If our organization is selected to participate in the LIFT Train-the-Trainer workshop, we agree to the following tasks listed above.

Signed:

Date

Authorized Agency Representative

Please Print Name:______

Application Form

Ohio Disability and Health Program

LIFT Train the Trainer Workshop

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Agency or Employer

Organization Name:

Address:

City:

State:Zip:

Phone:

Cell:

Fax:

E-mail:

Key Organization Contact (if other than Trainer)

Name:

Title:

Address:

City:

State:Zip:

Phone:

Cell:

Fax:

E-mail:

1. Why is your organization interested in participating in this project?

2. Participating organizations are expected to offer at least one round of training using the LIFT curriculum with people with intellectual or developmental disabilities. If selected what are your initial ideas about the following: (A short paragraph for each question is sufficient)

  1. Who would receive the LIFT training within your organization (how many people with disabilities, how many direct support staff)?
  1. Where would training sessions be held?
  1. In what month to you anticipate conducting the LIFT workshop?
  1. How do you expect this project to impact your organization and the people it supports?

E-mail completed forms to Erica Coleman - or fax forms with cover sheet to Erica Coleman to 513-803-0072 (scanning and emailing is preferred).

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