Minnesota Department of Health HIV Prevention Projects Proposal Review Committee Application 

NOTE: Individuals under the age of 18 are required to submit with their application written permission from a parent or guardian to participate in this process.  This must be signed by the parent or guardian.

Section I – Personal Information

Required Information:

In order to process your application, we need the following information.

Name:
Personal contact information: Personal contact information:
Preferred method of contact: Preferred method of contact:

Optional Information:

Work contact information: Work contact information:

The following information is requested in order to create a diverse review committee, however it is optional.  If you “prefer not to say” for any item please just skip it.

The information disclosed is public information and MDH may provide this information to reviewers and others if requested. Please do not share any information you wish to remain private.

Your cooperation in completing this form is appreciated.

Sex: Sex:
I am: I am:
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