Minnesota Council for HIV/AIDS Care and Prevention Application Form

Thank you for your interest in HIV care and prevention planning in Minnesota!

This community planning group is essential for the ongoing provision of prevention and care services in Minnesota. Member duties include identifying communities to target for prevention interventions, prioritizing service areas and allocating Ryan White HIV/AIDS Treatment Extension Act of 2009 funding for HIV care services. Applications for the Council are accepted throughout the year and are kept on file for one year. New members are elected as needed. The Council is a public body. The names of Council members are public information. All Council and committee meetings are open to the public. Meeting minutes are available to the public and are posted on the Council website: http://www.mnhivcouncil.org/

This volunteer position will require your attendance at the following:
1.   Participate in a New Member Orientation Session (6-8 hours)
2.   Serve a term of two (2) years; one (1) subsequent term is allowed contingent upon reappointment
3.   Attend monthly meetings and serve on at least one (1) standing committee
4.   Commit to a minimum of 8-10 hours per month to Council business; including attendance at Council meetings, committee meetings and preparation time
5.   Attend other training opportunities as appropriate
6.   Participate fully in all responsibilities as mandated by federal legislation

Members requiring mileage reimbursement for meetings will need to provide their valid driver's license number and street mailing address.

Completing this form will help the Membership and Training Committee assess the qualifications of applicants, and aid in their ability to make nominations for membership. If the committee determines you may fill a vacancy in representation or reflectiveness, we will contact you to schedule an interview, and you will have an opportunity to expand on your answers.

If you need assistance, including disability, completing this form contact Richard Puella, Minnesota Council for HIV/AIDS Care and Prevention, 525 Portland Ave S, MCL963, Minneapolis, MN 55415, Phone: 612-596-7894, 1-888-638-3224, richard.puella@hennepin.us

Contact information

(Required fields are indicated with *)

Your name*

Preferred Gender Pronouns (e.g., he/him, she/her, they/them)

Agency Name (if applicable)

Street Address

City

State

Zip

Cell phone

Work phone

Home phone

Fax

Date of birth

Format: mm/dd/yyyy

E-mail address*

Can this email address be used for Council correspondence?

Do you check your email at least two times a week?

Please check all that apply:

Gender

Race and/or Ethnicity

Sexual Orientation

HIV and Consumer Status

HIV Status

I am living with HIV/AIDS
I am HIV negative (HIV -)
I do not know my HIV status
I do not wish to reveal my HIV status

HIV Exposure

To the best of your knowledge, what was most likely your HIV exposure risk?

Do you consider yourself at risk or high-risk of HIV infection?

Yes
No
I decline to share this information

Consumer Status

I currently receive, or in the past year have received HIV services
I have not received HIV services in the past year
I decline to share this information

Current or former injection drug user (IDU)

Yes
No
I decline to share this information

Have you been incarcerated in the past 3 years?

Yes
No
I decline to share this information

Are you co-infected with HIV and Hepatitis B or Hepatitis C?

Yes
No
I decline to share this information

Agency Affiliation

Are you currently employed by, doing 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.)

Employer

Position

Do you have employer permission to attend Council and Committee meetings as part of your job?

Have you attended MN Council for HIV/AIDS Care and Prevention meetings in the past?

Yes. Please describe your involvement:
No

Service Sector Affiliations
Are you a provider of any of these services?

Topics	Provider
Health-care provider, including Federally Qualified Health Centers	Health-care provider, including Federally Qualified Health Centers, Provider
Community-based organization serving affected populations/AIDS Service Organization (ASOs)	Community-based organization serving affected populations/AIDS Service Organization (ASOs), Provider
Social services, including housing and homeless services	Social services, including housing and homeless services, Provider
Mental health services	Mental health services, Provider
Substance-abuse services	Substance-abuse services, Provider
Local public health agency	Local public health agency, Provider
Hospital planning agency or other health-care planning agency	Hospital planning agency or other health-care planning agency, Provider
Affected community member (either HIV community or underserved population community)	Affected community member (either HIV community or underserved population community), Provider
State Medicaid Program	State Medicaid Program, Provider
Ryan White Part B Program	Ryan White Part B Program, Provider
Ryan White Part C Program	Ryan White Part C Program, Provider
Ryan White Part D Program	Ryan White Part D Program, Provider
Organizations addressing the needs of children, youth and families with HIV	Organizations addressing the needs of children, youth and families with HIV, Provider
Other Federal HIV Program, including HIV prevention programs	Other Federal HIV Program, including HIV prevention programs, Provider
Formerly-incarcerated person living with HIV/AIDS or representative of this group	Formerly-incarcerated person living with HIV/AIDS or representative of this group, Provider

What special skills can you bring to the group? Mark all that apply:

In 50 words or less, please tell us why you are interested in joining the group.
Please note: This information is shared with Council members at the time your name is considered for membership.

By signing this application, you authorize the Council staff to provide this information to the Membership and Training Committee members for review.

You are not legally required to provide any of the requested information. However, it generally is to your benefit to provide it. If you do not provide the information asked, the Council will be unable to determine if you meet eligibility criteria for Council membership and the Council may not be able to contact you. All data collected and stored may be shared with the Membership and Training Committee and Council staff, or only upon court order or the State Auditor as authorized by law.

Yes. Today's Date:
No

Note: Applications are not complete until you have read and signed each of the Council policy pages. Email your application to: richard.puella@hennepin.us.

Questions? Contact Richard Puella, Minnesota Council for HIV/AIDS Care and Prevention, 525 Portland Ave S, MCL963, Minneapolis, MN 55415, Phone: 612-596-7894, 1-888-638-3224, richard.puella@hennepin.us.
(Contact Richard for the fax number if you would like to fax your application.)