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ORGANIZATION COMMITMENT FORM
Ohio Disability and Health Program
LIFT: Living Independently from Tobacco Train-the-Trainer Workshop
Columbus, Ohio
Applications must be received prior to workshop start date.
Background information: The purpose of this project is to increase the number of LIFT Trainers in Ohio in
order to positively impact the quality of life of Ohioans with developmental disabilities. The project is offering
training and certification to providers serving people with intellectual and/or developmental disabilities (IDD).
Selected participants will be trained on the LIFT Curriculum and will implement the program within their
respective organizations. To learn more about the LIFT curriculum visit: http://bsch.phhp.ufl.edu/ - enter
“LIFT” in the search box.
The sponsors of this project, Ohio Disability and Health Program (ODHP), receive federal funding and are
required to show the impact they have in improving people with disabilities’ quality of life and inclusion in the
community. The impact is demonstrated by sharing the LIFT data that is collected by LIFT Trainers as part of
the LIFT workshops, with the funding agencies. Therefore, it is very important that certified LIFT Trainers
collect the data on how many people with disabilities participated in LIFT workshops, what they gained from it
and how it improved their health and quality of life.
Your role: If you choose to apply and your organization is selected to participate, the Ohio Disability and
Health Program (ODHP) will ask that you agree to complete the following tasks:
•
Send one or two people from your organization to the Train-the-Trainer (T-the-T) workshop to be
trained on the Living Independent from Tobacco (LIFT) curriculum and become a certified LIFT
Trainer. The workshop participant(s) should fall into one or more categories within their respective
organizations: Program manager, site coordinator, or designated training specialist who wishes to
become a certified trainer within the organization.
•
After completing the T-the-T workshop, each participant will be expected to implement the
curriculum within their respective organizations; within one year following the training. Sites will be
asked to:
o Conduct the workshop.
o Track and report the number of workshops and participants who have successfully
completed the workshops to be shared with ODHP team members.
Risks: We don’t know of any risks in participating in this project.
Benefits: If your organization is selected to participate in the project, you will have:
•
•
A chance to participate in a T-the-T workshop to train on an exciting, tobacco cessation program
specifically developed for people with disabilities;
A chance to introduce and implement the curriculum in your organization;
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The opportunity to become a certified trainer on a federally recognized evidence-based health
promotion curriculum.
Compensation: Selected participants will partake in a T-the-T workshop on the curriculum at no charge.
Workshop participants will receive a curriculum (training guide) to use when delivering their workshops.
Contacts and Questions: Please contact Erica Coleman with any questions: 513-803-4399 or
Erica.Coleman@cchmc.org
If our organization is selected to participate in the LIFT Train-the-Trainer workshop, we agree to the following
tasks listed above.
Signed:
Date
Authorized Agency Representative
Please Print Name:
________
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Application Form
Ohio Disability and Health Program
LIFT Train the Trainer Workshop
Agency or Employer
Organization Name:
Address:
City:
State:
Zip:
Phone:
Cell:
Fax:
E-mail:
Key Organization Contact (if other than Trainer)
Name:
Title:
Address:
City:
State:
Zip:
Phone:
Cell:
Fax:
E-mail:
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1. Why is your organization interested in participating in this project?
2. Participating organizations are expected to offer at least one round of training using the LIFT
curriculum with people with intellectual or developmental disabilities. If selected what are your
initial ideas about the following: (A short paragraph for each question is sufficient)
a. Who would receive the LIFT training within your organization (how many people with
disabilities, how many direct support staff)?
b. Where would training sessions be held?
c. In what month to you anticipate conducting the LIFT workshop?
d. How do you expect this project to impact your organization and the people it supports?
E-mail completed forms to Erica Coleman - Erica.Coleman@cchmc.org or fax
forms with cover sheet to Erica Coleman to 513-803-0072 (scanning and
emailing is preferred).
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