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Council/Grantee Memorandum of Understanding
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NY HIV Planning Council
Meet the Council
About the Council
Committees
Planning Council
Executive Committee
Consumers Committee
Integration of Care Committee
Priority Setting and Resource Allocation Committee
Needs Assessment Committee
Tri-County Steering Committee
Governing Documents
Mayor’s Executive Order
Council By-laws
Council Grievance Procedures
Grantee Grievance Procedures
Council/Grantee Memorandum of Understanding
Contact the Council
Our Impact
Calendars
Planning Council Events
Community Events
Service Locator
PHS Funded Service Locator
NYC HealthMap
HRSA Ryan White Data Warehouse
TransAtlas by Callen-Lorde
Resources
HIV Data, Reports & Resources
Consumer Resources
Grantee Resources
Membership Form
Membership Form
Contact Information
Name
*
First Name
*
Last Name
Age
*
19 and under
20-29
30-39
40-49
50-59
60 and Over
Organization
Complete Mailing Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Alternate Number
*
May we call you at home or work?
*
Yes
No
Cell Phone
*
Email Address
*
Demographics
Gender
*
Female
Male
Transgender
Race/Ethnicity
*
African-American / Black
Latino / Latina
White
Asian / Pacific
Native American
Decline to Answer
Other:
County / Borough of Residence
*
Bronx
Brooklyn
Manhattan
Queens
Staten Island
Tri-County
Other:
HIV Status
*
I am a person living with HIV/ AIDS
I am NOT a person living with HIV/ AIDS
Status unknown or decline to answer
Do you receive -- or are you the parent/guardian of a child who receives -- HIV-related services from an agency that receives Ryan White Part A funding?
*
Yes
No
Unsure
Representation
Tell us which of the following groups you represent. Choose at least one, but no more than three, whose concerns you could represent on the Planning Council.
*
Affected communities, including PLWHA and historically underserved populations
Health care providers, including federally qualified health centers
AIDS service organizations and CBOs serving affected populations
Social service providers
Mental health providers
Local public health agencies
Hospital planning agencies or other health care planning agencies
Non-elected community leaders
Grantees under Part C
Grantees under Part D
Grantees of other Federal HIV programs, including but not limited to HIV prevention programs
Representatives of the incarcerated/prison releasees or formerly incarcerated PLWH who have been released in the previous three years
PLWHA co-infected with Hepatitis C or B
If you choose more than one, number them in priority order.
Most important group
*
Second most important group
Third most important group
Briefly describe why you feel qualified to represent the group(s) you chose above.
Experience & Background
1. What makes you a good candidate for membership on the Planning Council & Why are you seeing appointment to the Planning Council?
2. How would your participation on the Planning Council benefit people living with HIV/AIDS?
3. Describe trainings that you have taken related to HIV community planning, the Ryan White program, or related areas that have helped you prepare for a role as a Planning Council member.
Committee Choice
Council members are expected to serve on a committee. If appointed, to which committee would you seek appointment? (For descriptions of the roles and responsibilities of each committe, please see their respective pages on the website). Please number your top 3 choices.
*
Consumers Committee
Needs Assessment
Integration of Care
Priority Setting & Resource Allocation
Finance
Policy
Rules & Membershi
Tri-County Steering Committee
Please check them in order of importance.
Most interested committee
*
Second most interested committee
*
Third most interested committee
*
Affiliation
Identify any agency where you serve as employee, consultant, or board member. Do not include service on consumer advisory boards or as an unpaid volunteer. Agency affiliation does not disqualify you for appointment, but may require that you not participate in certain voting procedures.
Agency 1
Agency 2
Capacity 2
(employee, consultant, board member)
Agency 3
Capacity 3
(employee, consultant, board member)
Résumé
Please upload your resume if you have one.
Accepted file types: pdf, doc, docx.
Affirmation of Member Commitment
Please read each statement and check the accompanying box.
If appointed by the Mayor, I will commit to the following:
*
Serve on the Council and serve on a committee (A minimum 4 hours per month);
Participate in all Planning Council meetings (4th Thursday of the Month);
Prepare for each meeting by reading any pre-distributed materials;
Consider the needs of the community as a whole and not allow my concern to be limited to personal or special interests;
Disclose any potential conflicts of interest to the Council or its committees;
Participate in Planning Council orientation and trainings
Confirmation
*
I have considered my personal and professional obligations and do not believe them to be a barrier to my active participation as a committee member.
I certify that all statements made in this application are true.
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