CBO Bench Technical Assistance Request Form

Baseline Information

Jurisdiction applying for technical assistance:

Contact person name:

Contact Email:

Name of project:

Project Description

Briefly describe the project including overall goals:

Project timeline (anticipated) and timeframe for community engagement:

Community Impact: What communities might be affected by the potential project outcomes? How might they be impacted?

Community Input: How will community input influence the project and decisions being made?

Support: What level of support is desired for this project? Please select one level of support.

Light: Limited Communication Engagement Support

Medium: Singular Event or Strategy Engagement Support

Heavy: Multiple Event or Strategy Engagement Support

Specify which type of activities are anticipated

Target audience for community outreach: What geographic region, language group, and/or other demographic target (such as race/ethnicity, age, socioeconomic status, etc.) are you trying to reach?

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