AMSR Proposal Form

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Training Details		Client		Trainer(s)		Participant Manuals		Venue		Registration		Continuing Education Credits		Contract and Invoicing		Additional Information

Your Name
N/A

Required First Required Last
Your Email *
N/A
Training Type *
N/A

TOT = Training of Trainers
Curriculum *
N/A

Outpatient
Inpatient
Substance Use Disorder
Direct Care Outpatient
Direct Care Inpatient

If you are unsure what the different curricula mean, please email us at amsr@edc.org. For TOTs, Outpatient or Inpatient will automatically include the Direct Care version.
Training Start Date *
N/A

MM/dd/yyyy

1 day training: enter date of training. Split training: enter date of first half. TOT: enter first day of training. (Proposals must be submitted at least 3 weeks ahead of the training start date to ensure trainings are approved.)
Training End Date *
N/A

MM/dd/yyyy

1 day training: enter date of training. Split training: enter date of second half (must be within 1 week of first half). TOT: enter last day of training.
Training Start Time
N/A

HH

MM

AM / PM

Minimum time required per curriculum (add more for breaks/lunch): Outpatient, Inpatient, and SUD - 6.5 hours, Outpatient Direct Care - 3.5 hours, Inpatient Direct Care - 3.5 hours
Training End Time
N/A

HH

MM

AM / PM
Training Date/Time Details
N/A

If there are details about the date and time of the training that don't fit into the fields above, please add it here. For example, if a TOT is not 3 consecutive days, add the date of the second day.

Sponsoring Organization *
N/A

The sponsoring organization is the one paying for the training.
Sponsoring Org Address
N/A

Required Street Address Address Line 2 Required City Required State/Region/Province Required Postal / Zip Code

Required
Country
Coordinating Organization (if different from Sponsoring Organization)
N/A

The coordinating organization is responsible for the setup and implementation of the training. For example, a state may pay for the training (Sponsoring) which individual organizations within the state set up (Coordinating).
Point of Contact for the Training (PC)
N/A

Required First Required Last
PC Email *
N/A
PC Phone *
N/A
PC Alternate Phone
N/A

N/A

I understand the need for an assigned trainer is associated with additional training fees. I understand the need for an assigned trainer is associated with additional training fees.

EDC will provide an authorized trainer (Trainer Fee) along with travel or technology fees as determined by the training details.
Does your organization have an authorized AMSR trainer that will be leading this training? *
N/A
Trainer 1
N/A

Required First Required Last

If you need a trainer assigned, leave this blank.
Trainer 2
N/A

First Last

If you need a trainer assigned, leave this blank.
Trainer(s) to be contacted by: *
N/A

Client
ZSI AMSR Team
Are the trainer(s) employed by client? *
N/A

Yes (trainer compensated by client)
No (trainer fee will be charged, trainer compensated by EDC)
This page is not applicable for Pre-Orders, click Next to continue.

NOTICE: It is the responsibility of the Sponsoring Organization to ensure each participant receives their own manual to keep. Any unauthorized use of manuals is strictly prohibited by EDC.
Number of Participant Guides to be delivered: *
N/A

Maximum number of attendees per training: 50 for regular, 25 for TOT. If you would like manuals to be shipped up front for multiple trainings, you can put the total number here on the the first training, and 0 for the subsequent trainings.
Number of Leader Guides to be delivered: *
N/A

For a TOT, each participant will need 1 Participant Guide and 1 Leader Guide.
KENTUCKY: Number of Participant Guides to be shipped by Beck *
N/A

Maximum number of attendees per training: 50 for regular, 25 for TOT.
KENTUCKY: Number of Leader Guides to be shipped by Beck *
N/A

For a TOT, each participant will need 1 Participant Guide and 1 Leader Guide.
KY DBHDD: You must forward your completed training request to Beck Whipple (beck.whipple@ky.gov) in order to have manuals shipped.
Estimated number of attendees for this training:
N/A
Would you like manuals mailed to one location or individually to each participant? *
N/A

There is a fee for individual mailings.
Manual Recipient Name (MR)
N/A

Required First Required Last
MR Phone *
N/A
MR Alternate Phone
N/A
MR Email *
N/A
Manual Shipping Address
N/A

Required Street Address Address Line 2 Required City Required State/Region/Province Required Postal / Zip Code

Required
Country
If you have entered a PO Box, please choose a new address. We cannot ship to PO Boxes.

Is your training online or in person? *
N/A
Do you require platform and staffing support? (Additional cost) *
N/A

Select no if you will host the event on your own platform and provide tech staff to run it. **Clients requesting ZSI trainers must select Yes**
Venue Name *
N/A

As applicable: organization name, building name, room number
Venue Address
N/A

Required Street Address Address Line 2 Required City Required State/Region/Province Required Postal / Zip Code

Required
Country

Not required for online trainings.
Is this venue accessible to people with disabilities? *
N/A

Yes
No
Unsure
This page is not applicable for Pre-Orders, click Next to continue.

N/A

We need a registration page set up by the ZSI/AMSR team. (free) ZSI/AMSR will provide registration. Client will provide registration. We need a registration page set up by the ZSI/AMSR team. (free)

Leave unchecked if you will be managing your own registration process.
Who will manage the registration process? *
N/A

Registration must be managed through ZSI if individual mailings for manuals is selected.
Registration information:
N/A

Link or contact person; any additional details/requests
Registration fee paid by participants, if any: USD
N/A
N/A

This is a closed registration (do not advertise on ZSI website) Training will not be advertised. Training will be advertised. This is a closed registration (do not advertise on ZSI website)

UNCHECK if you would like training to be advertised on our website.
This page is not applicable for Pre-Orders, click Next to continue.

For AMSR Outpatient, Inpatient, and SUD, we provide 6.5 hours of continuing education (CE) credits from a variety of boards. As CE boards are subject to change, please visit our website for the latest availability: https://solutions.edc.org/solutions/zero-suicide-institute/amsr/credits.

No CE credits are provided for Direct Care Outpatient or Direct Care Inpatient trainings.

Note: Continuing Medical Education (AMA CME) credits have been discontinued. Kentucky Marriage and Family Therapist (KY MFT) credits are now provided through the state of Kentucky. This program is approved to provide Continuing Education Credits by APA which is accepted by the BBS for CA licensees for LMFT, LCSW, LPCC, and LEP for 6.5 CE Credits.
(Outpatient) Please select the CE credits requested for this training:
N/A

If the incorrect curriculum is showing, please go back to the curriculum question on page 1.
(Inpatient) Please select the CE credits requested for this training:
N/A

If the incorrect curriculum is showing, please go back to the curriculum question on page 1.
(SUD) Please select the CE credits requested for this training:
N/A

If the incorrect curriculum is showing, please go back to the curriculum question on page 1.
This page is not applicable for Pre-Orders, click Next to continue.

N/A

This training will use manuals that have already been purchased through Zero Suicide Institute, and does not need a contract created. This training will use manuals that have already been purchased through Zero Suicide Institute, and does not need a contract created.

If you are unsure if you have manuals remaining on a previous contract, please contact amsr@edc.org first.
Contract Signatory Name (CS):
N/A

Required First Required Last

The contract signatory is the person who will sign the contract with Zero Suicide Institute. They must be authorized to sign legally-binding contracts on behalf of your organization.
CS Title
N/A
CS Phone *
N/A
CS Email *
N/A
Contract Router Name (CR):
N/A

First Last

If the contract should be routed through another person (i.e. not sent directly to the Contract Signatory), list them here.
CR Email
N/A
Invoice Recipient Name (IR):
N/A

Required First Required Last
IR Email *
N/A
IR Phone *
N/A
Invoicing Address
N/A

Required Street Address Address Line 2 Required City Required State/Region/Province Required Postal / Zip Code

Required
Country

Any other information you want to provide:
N/A
How did you hear about AMSR?
N/A

AMSR Trainer
Zero Suicide Event
Conference
Colleague or Friend
Web or Google Search
Other
Training Event Status *
N/A
Please be sure to click the submit button to complete your training request.

A Zero Suicide Institute staff member will be in touch within a few days to confirm your request.

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AMSR Proposal Form

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