CHCAMS TA Request Form

To provide health centers in Mississippi with the most appropriate technical assistance (TA), the Community Health Center Association of Mississippi is formalizing our process. By filling out this form, we will be able to provide your organization with tailored TA that is specific for your agency’s needs. Please allow up to 48 hours for someone to respond to your request.

Date*
MM slash DD slash YYYY
Name*
First Last
Title*
Name of Organization*
Email Address*
Work Phone Number*
Fax Number
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Detail description of TA request concern or issues:*
CHCAMS: What was conducted during this TA request?
List the name(s) of the CHCs staff.*
CHCAMS Team Member*
CHCAMS Team Member Email Address*
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