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2014 MN HIV Services Planning Council Membership Application
The Planning Council is a public body. The names of Planning Council members are public information. All Planning Council and committee meetings are open to the public. Meeting minutes are available to the public and are posted on the MN HIV Services Planning Council website.
By law the membership of the Planning Council must reflect the local HIV epidemic. This requires during the application process asking some personal and sensitive questions. You will have the option to not answer or not publicly share your answers to some of the questions on the application. Applications are
not
made available to the public.
Please keep your answers brief, there will be time to provide more information during the interview. Enter N/A (not applicable) where appropriate. You are not required to answer any of these questions, but the more complete the application is the better we will be able to assess your qualifications for serving on the Planning Council. Please contact Council staff at 612-596-7894 (888-638-3224 toll free) if you have any questions or need help completing the application.
section 1: contact information
If selected for membership this contact information will be shared with Planning Council members and government representatives affiliated with the Planning Council.
*
Indicates required field
Name
*
First
Last
Work Phone Number
*
Cell Phone Number
*
Home Phone Number
*
Email
*
Many communications about meeting notices and document review are sent via email. Do you check email at least twice per week?
*
Yes
No
Address
*
Line 1
Line 2
City
State
Zip Code
Country
section 2: categories of representation
The Council is required to have participants from all sectors of the epidemic. These questions help us determine whether or not we are meeting our membership goals.
What is your gender?
*
Male
Female
Transgender
What is your age?
*
Less than 18
18-24
25 or older
What is your race? (check all that apply)
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Asian / Pacific Islander
Black / African American
Black / African Born
Caucasian
Hispanic / Latino
Native American / Alaskan
Other
Ethnicity
*
Hispanic / Latino
Consumer Status
*
I currently, or in the past year, have received HIV services.
I have not received HIV services in the past year.
Decline to share this information.
Where do you work?
*
What is your job title?
*
Do you have employer permission to attend Council meetings as part of your job?
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Yes
No
Are you currently employed by, do consulting work for, or sit on the board of directors of an organization that provides HIV/AIDS services? (This does not include consumer boards or community advisory boards.)
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Yes
No
Sexual Orientation / Behavior
*
Gay
Bisexual
Hetrosexual
Lesbian
Man who has sex with men
Woman who has sex with women
Decline to share this information
Transmission / Risk Categories
*
Hemophilia
Blood Recipient
Injection Drug Use (past or present)
Decline to share this information
Are you a provider of any of the following services? (check all that apply)
*
Health-care provider, including Federally Qualified Health Centers
Community-based organization serving affected populations/AIDS Service Organizations (ASOs)
Social services, including housing and homeless services
Mental health services
Substance-abuse services
Local public health agency
Hospital planning agency or other health-care planning agency
Affected community member (either HIV community or underserved population community)
State Medicaid Program
Ryan White Part B Program
Ryan White Part C Program
Ryan White Part D Program
Organizations addressing the needs of children, youth, and families with HIV.
Other Federal HIV Program, including HIV prevention programs
Formerly-incarcerated person living with HIV/AIDS or representative of this group
Are you a consumer of any of the following services? (check all that apply)
*
Health-care provider, including Federally Qualified Health Centers
Community-based organization serving affected populations/AIDS Service Organizations (ASOs)
Social services, including housing and homeless services
Mental health services
Substance-abuse services
Local public health agency
Hospital planning agency or other health-care planning agency
Affected community member (either HIV community or underserved population community)
State Medicaid Program
Ryan White Part B, C, or D Program
Organizations addressing the needs of children, youth, and families with HIV.
Other Federal HIV Program, including HIV prevention programs
Formerly-incarcerated person living with HIV/AIDS or representative of this group
Are you a non-elected community leader?
*
Yes
No
Are you co-infected with HIV and Hepatitis B or Hepatitis C?
*
Yes
No
Have you been incarcerated in the past 3 years?
*
Yes
No
section 3: Special interestes and skills
What special skills can you bring to the Planning Council? (check all that apply)
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Leadership
Program planning
Budgeting/Financial management
Research or technical training in HIV/AIDS
HIV medical care
Professional/technical writing
Community organizing
Program evaluation
Group process
Needs assessment
Quality management
Which committees do you think you might have an interest in joining?
*
Planning & Priorities
Needs Assessment & Evaluation
Operations
Community Voice (HIV+ members only)
Have you attended Planning Council or Planning Council committee meetings in the past?
*
Yes
No
In 50 words or less, please tell us why you are interested in joining the MN HIV Services Planning Council. (Please note: This information is shared with Council members at the time your name is considered for membership).
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By typing my name below, I authorize the Minnesota HIV Services Planning Council staff to provide this information to Operations Committee members for review.
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Submit & Continue
