NEMA Committee Membership Application

COMMITTEE INTRODUCTION AND MEMBERSHIP APPLICATION INSTRUCTIONS FOR THE
NEWARK EMA HIV HEALTH SERVICES PLANNING COUNCIL

Thank you for your interest in the Ryan White Part A Planning Council. Please take a few minutes to read the information below as it is important to understand the work and responsibilities of all Planning Council committees and its committee members.

WHAT IS THE PLANNING COUNCIL?

The Newark Eligible Metropolitan Area (EMA) HIV Health Services Planning Council is responsible for prioritizing HIV/AIDS services based on community needs and allocating Ryan White Part A funding for these services. The Planning Council has seats for up to 34 members who represent a variety of community agencies, stakeholders, state agencies, consumers, and individuals affected by HIV/AIDS in the counties of Essex, Union, Morris, Sussex and Warren. For more information, visit www.nemaplanningcouncil.org.

The NEMA Planning Council is supported by the United Way of Greater Union County known as the Office of Planning Council Support, and works in close collaboration with the Ryan White Unit of the Newark Department of Health & Community Wellness.

COMMITTEE MEMBERSHIP

All members are expected to have the support of their employer (if employed) and to commit to the following:

Participation in monthly Planning Council committee meetings
Preparation for each meeting by reading any materials e-mailed to you prior to the meeting.
Consideration of the needs of the community over individual or agency needs

APPLICATION SUBMISSION
For further information on the application or the membership selection process please contact the Council Support Staff at Roberto Benoit roberto.benoit@uwguc.org or Carla-Ann Alexander carla-ann.alexander@uwguc.org

SECTION 1: CONTACT INFORMATION

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* Full Name (Please provide name as you would like it to appear in communications):

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* Full Home Address (Please include street name city, county, and zip code):

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* County

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* Home Phone Number:

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* Cell Phone Number:

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* Personal Email Address (if available):

SECTION 2: EMPLOYMENT INFORMATION

(If applicable.)

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* Current Place of Employment and/or Community Role:

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* Full Work Address (Please include street name city, county, and zip code):

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* Work Phone Number (leave blank if not applicable):

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* Fax Number (Leave blank if not applicable):

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* Work Email Address (Leave blank if not applicable):

SECTION 3: GENERAL INFORMATION

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* Email communication is used frequently between the Office of Planning Council Support, the Newark EMA HIV Health Services Planning Council, and its membership.
Do you have access to a computer or tablet?

Yes

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* If you do not have a computer or tablet, are you willing to work with our Support Staff to determine the best way for you to get information normally sent out by email? (This could mean you receive information via mail, text, or meeting Staff in-person to pick up information).

Yes

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* Have you ever served on the NEMA Planning Council?

Yes

If Yes, in what years?

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* Have you ever served on any of the NEMA Planning Council subcommittees?

Yes

If Yes, which one?

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* Do you currently serve as a member of any other HIV or health-services-related planning body, advisory board, commission, or workgroup?

Yes

If Yes, which one(s)?

SECTION 4: PERSONAL INFORMATION

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* Date of Birth (mm/dd/yyyy) (Optional but highly encouraged):

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* Gender

Male

Female

Transgender (male-to-female)

Transgender (female-to-male)

Additional gender identity (please specify):

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* Race/Ethnicity: (Choose all that apply to you):

White, not Hispanic

Black/ African American, not Hispanic

LatinX /Hispanic

Asian/Pacific Islander

American Indian/ Alaska Native

Multi-Race

Other (please specify):

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* Please select all that apply to you:

Receive Ryan White/ HIV Care Services

Provide Ryan White / HIV Care Services

Receive HIV Prevention Services

Provide HIV Prevention Services

Other (please describe):

SECTION 5: EXPERIENCE, SKILLS, AND BACKGROUND

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* Please describe any areas of relevant expertise gained from personal or professional experience that you would bring to the Planning Council.

LGBTQIA+ health needs

Needs Assessment

Case Management

General Public Health

Adolescent HIV health

Health Planning

Personal experience with health issues related to HIV

Legal Services

Substance Use Disorder Services

Leadership

Needs of incarcerated or formerly incarcerated people

Housing Services

General experience with the Ryan White Part A program

Community Health Needs

HIV Prevention

Priority Setting

Research

Healthcare Provider

Nutrition

Mental Health

Health Insurance (Medicaid)

AIDS Education and Training Center (AETC)

Oral Health

Emergency Services

Medical Transportation Services

Other (please specify)

SECTION 6: COMMITTEE SELECTION

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* The Planning Council has four standing committees that support work of the Planning Council. The Executive Committee guides the work of the Council. Which of the following standing committee(s) are you interested in and will actively participate in?
NOTE: There may be some restrictions on committee representation requirements as noted on their Operating Policies and Procedures. Therefore, you might not always be able to serve on the committee of your choice.

Please check all that apply.

Community Involvement Activities (CIA) – The CIA is a community-led advocacy group that encourages community participation in the priority planning and fund allocation process. The committee includes various initiatives such as community conversations, educational programs for consumers, health fairs, and other pertinent workshops and symposiums that address the HIV/AIDS epidemic. (Meetings occur every fourth Wednesday at 5PM)

Research & Evaluation (REC) – The REC is responsible for gathering and analyzing data for the development, implementation, and continual improvement of the Ryan White Health Care System in the Newark EMA. The Committee designs and implements sound research methodology to identify HIV/AIDS related needs as well as gaps in the current service delivery system. (Meetings occur every third Monday at 10AM)

Comprehensive Planning Committee (CPC) – The CPC works to develop recommendations for the prioritization and allocation of Ryan White funds in the Ryan White Part A funded HIV/AIDS care and treatment services within the Newark EMA (Priority Setting and Resource Allocation Plan) The committee also contributes to the update and monitoring of the five-year Integrated HIV/AIDS Prevention & Care Plan. (Meetings occur every second Friday at 9:30AM)

Continuum of Care Committee (COC) – The purpose of the COC is to develop and review service standards that promote quality care and treatment services for the HIV infected/affected communities within the Newark EMA. The committee also makes recommendations to the Planning Council and appropriate Council Committees regarding the development and implementation of effective strategies to address the HIV/AIDS epidemic. (Meetings occur every second Thursday at 10AM)

NOTE: There may be some restrictions on committee representation requirements as noted on their Operating Policies and Procedures. Therefore, you might not always be able to serve on the committee of your choice.

SECTION 7: STATEMENT OF COMMITMENT, SIGNATURE, & DATE

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* If appointed as a committee member, I can commit to the following minimum standards:

☐ To the best of my ability, I will attend regularly scheduled committee meetings.

☐ When I make recommendations and/ or decisions, I agree to consider the HIV/AIDS community as a whole, rather than just special interests or my personal perspectives.

☐ I agree to disclose any conflicts of interest I may have relative to issues that come before the Council and/ or Committees.

☐ I agree to keep information obtained due to participation in any activity related to the Planning Council confidential, unless otherwise given permission.

Yes

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* I acknowledge all the information provided in this application is true and correct to the best of my knowledge. I have considered my other personal and professional obligations and do not foresee them as a barrier to my full participation.

Please add your name below (in lieu of a signature):

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* Today's Date

Date / Time

Date

Time

AM/PM

***Please amend your membership application by contacting the Support Team whenever your contact, employment, or residence information changes.***

NEMA Committee Membership Application

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* Full Name (Please provide name as you would like it to appear in communications):

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* Full Home Address (Please include street name city, county, and zip code):

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* County

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* Home Phone Number:

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* Cell Phone Number:

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* Personal Email Address (if available):

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* Current Place of Employment and/or Community Role:

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* Full Work Address (Please include street name city, county, and zip code):

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* Work Phone Number (leave blank if not applicable):

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* Fax Number (Leave blank if not applicable):

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* Work Email Address (Leave blank if not applicable):

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* Email communication is used frequently between the Office of Planning Council Support, the Newark EMA HIV Health Services Planning Council, and its membership.Do you have access to a computer or tablet?

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* If you do not have a computer or tablet, are you willing to work with our Support Staff to determine the best way for you to get information normally sent out by email? (This could mean you receive information via mail, text, or meeting Staff in-person to pick up information).

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* Have you ever served on the NEMA Planning Council?

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* Have you ever served on any of the NEMA Planning Council subcommittees?

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* Do you currently serve as a member of any other HIV or health-services-related planning body, advisory board, commission, or workgroup?

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* Date of Birth (mm/dd/yyyy) (Optional but highly encouraged):

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* Gender

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* Race/Ethnicity: (Choose all that apply to you):

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* Please select all that apply to you:

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* Please describe any areas of relevant expertise gained from personal or professional experience that you would bring to the Planning Council.

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* I acknowledge all the information provided in this application is true and correct to the best of my knowledge. I have considered my other personal and professional obligations and do not foresee them as a barrier to my full participation.Please add your name below (in lieu of a signature):

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* Today's Date

* Email communication is used frequently between the Office of Planning Council Support, the Newark EMA HIV Health Services Planning Council, and its membership.
Do you have access to a computer or tablet?

* I acknowledge all the information provided in this application is true and correct to the best of my knowledge. I have considered my other personal and professional obligations and do not foresee them as a barrier to my full participation.

Please add your name below (in lieu of a signature):