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Needs Assessment Tool

Please complete the following questionnaire and CPI will provide you with a no-cost, no-obligation, Customized Cost Proposal for training at your organization! In addition you will receive a complimentary 10 Tips for Crisis Prevention poster (a $9.99 value) and a One-Day Seminar Pass to attend one of CPI's training programs at a location near you (a $459 value).

First Name:

Last Name:

Job Title:

Organization Name:

Org. Address:

City:

State/Province:

Zip/Postal Code:

Country:

Phone:

Fax:

Email:

1. How may we contact you?

	phone
	email
	mail
	fax

2. Please describe the nature of your business:

3. How many employees are at your organization?:

0-10
11-50
51-100
100+

4. Is your organization at one location or multiple sites:

One location
Multiple sites

5. How many employees do you plan to train?:

6. Are you working with a committee?:

Yes
No

If YES, please list the number of members and state the purpose of your committee.:

7. Are you the decision maker for on-site training?:

Yes
No

If NO, please provide the name of the person who is the decision maker and contact information:

8. Has a budget been established for training?:

Yes
No

9. Does your organization currently have crisis response/violence prevention policies and procedures?:

Yes
No
Not Sure

10. What date have you established to begin training your staff?:

11. How many Training Packet Proposals are you requesting?:

12. What is the deadline or date of your next meeting?:

13. Why are you interested in managing disruptive or assaultive behavior?:

14. If you are interested in this topic because regulations/legislation require training, please provide the name of the mandate or legislative action.:

15. Please list any additional information, comments, or questions you have regarding your on-site Needs Assessment.:

16. Where did you hear about CPI?:

17. Please enter the Priority Code from any printed material you received. (It is located near your name on the mailing label or in the lower right corner of the advertisement or order form.):

18. Please enter the Customer Code from any printed material you received. (It is located near your name on the mailing label.):

19. I would like to be contacted in the next 30 minutes by an On-Site Training Specialist.:

Yes
No

If YES, the phone number (if different than above) to reach me at right now is:

Call back service is available between the hours of 8:00 a.m. – 6:00 p.m. Central Time. Due to internet connectivity issues, if you do not hear from an On-Site Training Specialist within the next 30 minutes, please call toll-free 877.816.4524.

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