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 $399 value).

*First Name:
*Last Name:
*Job Title:
*Organization:
*Org. Address:
*City:
*State/Prov.
*Zip/PCode:
*Country:
*Day Phone:
Extension:
Fax:
*Email:

 

*1. How may we contact you? Please read our privacy policy.
Mail:	Yes	No
Phone:	Yes	No
Fax:	Yes	No
Email:	Yes	No

 

*2. Please send my complimentary, no-obligation customized cost proposal for (please choose one):

Nonviolent Crisis Intervention® training program: For human service professionals—more than five million trained!

Life Space Crisis Intervention Training

 

*3. Please describe the nature of your business:

 

*4. How many employees are in your organization?

0 – 10

11 – 50

51 – 100

100 +

 

*5. Is your organization at one location or multiple sites?

one location

multiple sites

 

*6. How many employees are you planning to train?

 

*7. Are you working with a committee?
Yes	No
If YES, please list the number of members and state the purpose of your committee:

 

*8. Has a budget been established for this training?
Yes	No	Uncertain
If YES, any information you can provide about the budget (amount, type, fiscal information, etc.) will assist CPI in providing you a more comprehensive training package proposal:

 

*9. 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:

 

*10. Does your organization currently have crisis response/violence prevention policies and procedures?
Yes	No

 

*11. What date have you established to begin training your staff?

 

*12. How many Training Packet Proposals are you requesting?

 

*13. What is the deadline or date of your next meeting?

 

*14. Why are you (or your facility) interested in the topic of managing disruptive and assaultive behavior?
type reasons for interest here
Other reasons (Please check all that apply):
Increase staff morale	Decrease seclusion and restraints
Increase safety	Decrease Worker's Compensation claims
Increase employee production	Valuable networking among staff
Reduce disruptive incidents	To be proactive
An incident occurred	Reduce assaultive incidents
To comply with regulation, legislation, or accreditation (If you select this option, please complete question 15 below.)

 

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

 

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

 

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. View sample.)

 

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

 

*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.–5:30 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 1-877-877-5389 at your convenience.

All fields must be filled in correctly to receive this offer. Offer valid while supplies last and shipped to facility address only. One request per organization please.