Peer Exchange Interest Form

Point of Contact Name *

First Name

Last Name

Point of Contact Phone Number *

Country

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Please check the mentor site(s) you feel you may best learn from. *

Select all that apply. Visit our Peer Exchanges page for more information on the host sites.

Franklin County Jail, MA

LaSalle County Correctional Facility, IL

During a visit to a mentor site, in what activities would you like to engage? *

Select all that apply

Tour the facility for ideas on MAT program setup (e.g. respecting confidentiality, ensuring COVID-19 safety)

Observe administration of medication

Meet with the medical team to discuss collaborating with security staff and/or clinical MAT issues unique to jails

Meet with the security team to discuss diversion management and other safety measures

Hear from individuals who are either currently in the program or recently released from custody about their experiences in the program

Other

Check all the boxes to certify that, if selected, your agency agrees to the following: *

Send up to three team members to visit the assigned mentor site.

Complete and submit a post-site visit evaluation form.

Complete a brief questionnaire and/or a follow-up interview to summarize the experience upon completion of the mentorship

How did you learn about COSSUP's TTA and Mentor Site Visit Initiative? *

Select all that apply

We are a current COSSUP grantee

Training/Conference

National Sheriffs' Institute

Other