Qualtrics Survey | PEWD Program Request Form

Requestor Name:

Are you UTRGV Faculty or Staff?

Yes
No

Identify UTRGV Department:

Name of Organization:

Requestor email:

Are you requesting:

Customized Training
New Continuing Education Training

Summary of Request for Customized Training: Briefly describe the training needs of your organization.

How many employees will participate in the training?

How many supervisors will participate in the training?

Describe key challenges your team is currently facing that this training could address?

What is the current skill level of the participants in the requested training?

Basic/Foundations
Intermediate
Advanced

Summary of Request for New Continuing Education Training: Briefly describe the adult education needs this program/seminar/workshop will address, if there are subject matter experts available to teach in your department, and what resources and materials are needed for the proposed program/workshop/seminar.

Proposed Program Dates:

Start date:

End date:

Program Request Information:

Total Program Hours

Frequency (days/weeks/months)

Estimated Program Fee / Budget (Ex. 500)

Does the Program Fee / Budget include (select all that apply):

Does the Program Fee / Budget include (select all that apply):
	Yes	No	I do not know
Program Material (study guide)	Yes	No	I do not know
Books	Yes	No	I do not know
Instructor Fees	Yes	No	I do not know
Travel Costs	Yes	No	I do not know
Administrative Overhead	Yes	No	I do not know
Equipment/Software	Yes	No	I do not know
Food	Yes	No	I do not know

Location (Select all that apply):

UTRGV Brownsville
UTRGV Edinburg
UTRGV Harlingen
Other

Identify "other" location: