TRACK C: APPLICATION TEMPLATE Integrating Adlescent Substance Abuse Screening, Brief Interventin and Treatment (SBIRT) thrughut Scial Wrk and Nursing Schl Educatin Request fr Applicatins (RFA) Track C: Instructr s Tlkit and Simulatin Prgram Implementatin (Fall 2016-September 30, 2017) Cmpleting the Track C applicatin signals yur interest in integrating adlescent SBIRT educatin int yur existing assciate, undergraduate, and/r graduate level scial wrk and/r nursing curriculum. This applicatin asks abut yur intentins fr enhancing the educatinal experience fr students, faculty/educatrs, field placement supervisrs, field instructrs, and preceptrs in schls f nursing r scial wrk. Please cmplete Steps 1 and 2 belw using this Track C: Applicatin Template: Step 1: Review the Minimum Technical Requirements (Technical Specificatins) fr nline simulatin training (RFA Appendix A) and cnfirm yur institutin cmplies with the requirements t run the SBI with Adlescents simulatin. Step 2: Prvide brief detail n yur plan t integrate the Adlescent SBIRT educatin int yur curriculum using the SBI with Adlescents simulatin prgram and Instructr s Tlkit. Infrmatin abut these materials is described here: http://sbirt.webs.cm/curriculum. 1
COMPONENTS OF THE APPLICATION STEP 1: Review the Technical Requirements in Appendix A. Cnfirm cmpliance here: Yes, I am able t meet the technical requirements t run the simulatin prgram. N, I am nt able t meet the technical requirements t run the simulatin prgram and chse nly t implement the Instructr s Tlkit educatinal materials. STEP 2: Cmplete items 1-12 belw t prvide infrmatin abut yur academic institutin and t prvide brief detail n yur plan t integrate the Adlescent SBIRT educatin int yur curriculum using the SBI with Adlescents simulatin prgram and Instructr s Tlkit. 1. Academic Institutin: What is the name f yur academic institutin, schl, department and/r prgram? 2. Primary Pint f Cntact: What is the name, title, email address, mailing address, phne number, and schl and/r department name fr the faculty/educatr wh will serve as the pint f cntact fr this prject? 3. Cllabratr Pint f Cntact: If there is anther schl and/r department participating with yu, what is the name, title, email address, mailing address, phne number, and schl and/r department name fr the cllabrating pint f cntact? 4. Current SBIRT Funding: Are yu currently receiving funds frm anther surce t implement SBIRT educatin int nursing and/r scial wrk educatin (e.g., SAMHSA, HRSA)? Please identify the funding surce. 5. IRB: D yu anticipate needing t submit an applicatin t yur schl's Institutinal Review Bard (IRB) t participate in the Track C RFA prgram? 6. Participatin in the Prject: Have yu r smene frm yur academic institutin, participated in any f the fllwing? Please list the persn(s) wh has participated in ne r mre f these activities belw. a. Mnthly Adlescent SBIRT Learning Cllabrative calls cnducted by NORC? b. A Walk-Thrugh call with the NORC prject team? c. The Kgnit Online SBIRT Review Grup? d. Track A Evaluatin RFA Prgram? 2
e. Track B Implementatin RFA Prgram? If yu have nt participated in any f the activities (a-e abve) r are new t the prject r Learning Cllabrative, please indicate that here. 7. Prgram Level: What is the level f prgram(s) in which the Adlescent SBIRT Instructr s Tlkit materials and/r SBI with Adlescents simulatin prgram will be used during yur participatin in the Track C implementatin perid? Assciates Undergraduate Masters Dctral Other (please describe) 3
8. Disciplines: In which discipline(s) will the Adlescent SBIRT Instructr s Tlkit materials and/r SBI with Adlescents simulatin prgram be used during the prgram perid? Scial Wrk Nursing Other (please describe) 9. Curses Please describe the specific curses in which yu plan t ffer the Adlescent SBIRT Instructr s Tlkit educatin materials and/r SBI with Adlescents simulatin prgram anytime between the fall f 2016-September 30, 2017: Name f Curse r Educatinal Experience Name (if ffering multiple sectins f same curse, please list each curse sectins separately): Prgram Level (e.g., Undergraduat e, Masters, Dctral): Curse Setting (e.g., Inpersn, Online, Hybrid): Estimated Number f students in curse: Semester(s)/Quarter(s ) Offered During Implementatin perid (e.g., Fall 2016, Spring 2017, Summer 2017). Please include apprximate start and end dates if knwn. Indicate Materials t be Implemented by Indicating either: Tlkit Only, Simulatin Only, r Bth Additinal Ntes/ Cmments: a. Implementatin f SBI with Adlescents Simulatin: If yu indicated abve that yu plan t use the SBI with Adlescents simulatin prgram, please briefly describe hw yu plan t integrate it int the curses listed abve. In yur descriptin please specify hw the simulatin will be assigned and if participatin will be mandatry r vluntary. 4
Please be specific in yur descriptin prviding the name f the curses if applicable. If yu d nt plan t use the SBI with Adlescents simulatin please prvide a brief explanatin as t why yur plan des nt include it. b. Implementatin f the Instructr s Tlkit Materials: If yu indicated abve that yu plan t use the Instructr s Tlkit educatinal materials, please describe hw yu plan t integrate the educatin int the curses listed abve (e.g., included as part f in-class instructin prir t assigning the nline simulatin prgram; educatin will be prvided t curse instructr s and preceptrs prir t implementing educatin with students). Please be specific in yur descriptin prviding the name f the curses if applicable. If yu d nt plan t use the Instructr s Tlkit, please prvide a brief explanatin as t why yur plan des nt include it. 10. Please describe wh will be respnsible fr assigning and prmting cmpletin f the preand pst-training surveys befre and after implementing the educatinal materials and/r simulatin prgram (e.g., curse instructr, department chair, etc.). What apprach r strategies will be used t prmte cmpletin f the pre- and pst-training surveys? 11. D yu have leadership supprt t participate in the Track C prgram (e.g., frm the dean, department chair, faculty/clleagues)? Have yu already r hw will yu engage yur leadership and thers t supprt its integratin int curricula/cursewrk. (There is n need t include dcuments f supprt, please just describe briefly.) 12. D yu anticipate any challenges with participating in the Track C? If yes, please briefly explain hw yu ll wrk t vercme these challenges. Please submit yur applicatin by email attachment in PDF r Wrd frmat t the NORC SBIRT Team at SBIRTTeam@nrc.rg. We lk frward t receiving yur applicatin. Thank yu, NORC s SBIRT Team 5
APPENDIX A: KOGNITO TECHNICAL REQUIREMENTS 6