Calocus Training Form – Fill Out and Use This PDF

Training Request Form – To Be Submitted to Agency‐Based CALOCUS/LOCUS Trainer

CALOCUS/LOCUS Training Request Form

Employee Information

*Do you need CALOCUS or LOCUS training? Please read and place a check in the box next to the criteria that is true for you before responding “yes” or “no.”

___Yes, I need to receive training on the CALOCUS and/or LOCUS, BECAUSE:

□I have never completed a LOCUS/CALOCUS assessment;

□I have never received LOCUS/CALOCUS training; OR

□It has been over one year since I completed a LOCUS/CALOCUS assessment.

If you checked any of the above criteria, you must attend training. Choose the type of training you will need (below), obtain appropriate signatures on this form, and deliver to your agency-designated CALOCUS/LOCUS trainer.

___No, I do not need to receive training on the CALOCUS and/or LOCUS, BECAUSE:

□I use the LOCUS/CALOCUS on a regular basis with my consumers; OR

□I have received LOCUS/CALOCUS training in the past;

If you checked any of the above criteria, you may opt out of training with your supervisor’s approval. Please obtain appropriate signatures on this form, and deliver to your agency- designated CALOCUS/LOCUS trainer.

If you need training, which type do you need?

□I work with children, youth and families; I need CALOCUS training

□I work with adults; I need LOCUS training

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(Signature) Employee	Date: mm/dd/yyyy
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(Signature) Supervisor or Designated Authority	Date: mm/dd/yyyy
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(Signature) Agency-Based CALOCUS/LOCUS Trainer	Date: mm/dd/yyyy

Please contact Ms. Joycelyn Alleyne of DMH Provider Relations, at Joycelyn.alleyne@dc.gov, or (202) 673-4305 if you have questions about completing this form

Form Last Revised 3/18/2009