STATEWIDE ROSC COMMUNICATION Ticket

Please fill out the form for any changes to ROSC staffing. Filling out this information will provide updates to Statewide ROSC and IDHS- Department of Behavioral Health and Recovery (DBHR).

Name:*

Lead Agency/Organization Name:*

Reason for completing ticket:*If replacing staff, write name of person that is being replaced:

Effective Date of Change*:

ROSC Council Project Service Area (County/Community):*

ROSC Staff Project Role:*If Other:

Email Address:*

Phone Number:*

Street Address:*City:*State:*Zip Code:*

Other Information/Comments:

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The Center for Community Engagement is funded in full or in part through a State Opioid Response Grant (TI085769) to the Illinois Department of Human Services, Division of Behavioral Health and Recovery, from the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration.