Technical Assistance Request Form The MHLIC offers technical assistance (TA) to meet the needs of the maternal health community including health care and public health professionals, state health agencies, community-based organizations, and other groups that serve the maternal health community. Please submit a TA request to the MHLIC if you need assistance with a maternal health or capacity building topic. For questions, please email firstname.lastname@example.org. First nameLast nameTitleOrganizationEmailPhone numberState or JurisdictionMHLIC Maternal Health Topics (check all that apply): Maternity care services in medically underserved communities Maternity care workforce shortages Postpartum care Patient and provider education and awareness related to maternal mortality and severe maternal morbidity State maternal mortality review committees Innovative and evidence-informed interventions and strategies to improve maternal health outcomes Use of data in designing and implementing innovative and evidence informed strategies (including using electronic health records to benchmark progress for quality improvement) Data collection and evaluation of innovative and evidence-informed interventions and strategies Maternal telehealth and telemedicine strategies (e.g., mobile applications, remote pregnancy monitoring of specific conditions, etc.) Other areas to address emerging maternal health issues Capacity Building Topics (check all that apply): Effective engagement to support maternal mortality/SMM initiatives (Provider Engagement, Community Engagement, Coalition Building) Health equity (Equity Assessments, Equity Coaching, Health Impact Assessments, Equity Framing) Systems leadership (Appreciative Inquiry, Adaptive Actions, System Support Mapping, Causal Loop Diagramming, Whole System Mapping) From Knowledge to Action (Selection of Evidence-Based Interventions, Adaption of Evidence for Context, Building Evidence through Practice, Implementation Supports/Drivers) Other Topic(s):Other areas you might want TA in (e.g. AIM Program, telehealth implementation, telehealth policy/finance, community healthcare worker reimbursement, strategic planning, implementation tools, leadership tools, system tools, conflict resolution, consensus building). If you have any questions or concerns, please email email@example.com. EmailThis field is for validation purposes and should be left unchanged.