Backup — original pdf

Backup

Austin HIV Planning Council Member Interest Ques(cid:415)onnaire Applicant Information Name Date County of Residence Employer Position Title Type of Membership ☐ Voting ☐ Non-voting Conflicted ☐ Yes ☐ No Questions 1. How did you hear about the HIV Planning Council? 2. What inspired you to apply? 3. Have you received any training or education related to HIV, public health or any other experience you feel is relevant? Aus(cid:415)n HIV Planning Council: Member Interest Ques(cid:415)onnaire 1 Austin HIV Planning Council Member Interest Ques(cid:415)onnaire 4. Do you or a member of your household receive Ryan White Part A services? 5. Do you require any accommodations in order to attend meetings? 6. Are you able to commit 4-6 hours each month to Planning Council activities? Additional Notes Aus(cid:415)n HIV Planning Council: Member Interest Ques(cid:415)onnaire 2 Austin HIV Planning Council Member Interest Ques(cid:415)onnaire HRSA Categories ☐ Health Care Providers, Including Federally Qualified Health Centers ☐ Community-based organizations serving a(cid:431)ected populations and AIDS Service Organizations (ASOs) Social Service Providers, including providers of housing and homeless services ☐ ☐ Mental Health Providers ☐ ☐ ☐ Hospital planning agencies or health care planning agencies Substance Abuse Providers Local Public Health Agency ☐ A(cid:431)ected communities, including PLH, members of a federally recognized Indian tribe as represented in the population, individuals co-infected with hepatitis B or C and historically underserved groups and subpopulations ☐ Non-elected community leaders ☐ ☐ ☐ Grantees under subpart II of part C (Title II early intervention) State government (including State Medicaid Agency) State agency and the agency administering the program under part B. Representatives of organizations with a history of serving children, youth, women, and families living with HIV and operating in the area. Grantees under other Federal HIV programs, including but not limited to providers of HIV prevention services Representatives of individuals who formerly were Federal, State, or local prisoners, were released from the custody of the penal system during the preceding 3-years and had HIV/AIDS as of the date on which the individuals were released. ☐ HIV/AIDS Prevention Provider Checklist Attend Business Meeting Boards and Commissions’ Application Letter of Recommendation Resume ☐ A ☐ AA ☐ H ☐ W ☐ PI ☐ Other Race/Ethnicity Recommendations ☐ Care Strategies and Engagement ☐ Finance and Assessment Aus(cid:415)n HIV Planning Council: Member Interest Ques(cid:415)onnaire 3 ☐ ☐ ☐ ☐ ☐ ☐ ☐