Eligibility Assessment for National Learning Community for HIV CBO Leadership

Your unique ID number is:
the first two letters of your first name,
the first two letters of your last name,
the month of your birth,
and the day of your birth.
For example: Luisa Ramos, May 29
would be LURA-0529.

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* UNIQUE IDENTIFIER

First two letters of your first name

First two letters of your last name

The month of your birth (two digits)

The day of your birth (two digits)

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* First Name

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* Last Name

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* Work email address

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* Organization

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* What region are you located in?

Northeast (CT, ME, MA, NH, NJ, NY, PA, RI, VT, Puerto Rico, US Virgin Islands)

Midwest (IL, IN, IA, KS, MI, MN, MO, NE, ND, OH, SD, WI)

South (AL, AR, DE, District of Columbia, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX, VA, WV)

West (AK, American Samoa, AZ, CA, CO, Guam, HI, ID, Marshall Islands, Micronesia, MT, NV, NM, Northern Marianas, OR, Palau, UT, WA, WY)

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* What is your management level?

Entry-level manager

Mid-level manager

Senior-level manager

Executive director

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* How did you find out about the Learning Community?

Website

Social media

Email from C4H

Email from CPN

Referral

Other (please specify)

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* We are committed to making the C4H Learning Community accessible and inclusive for people with disabilities. If you choose to, please share any disabilities you have or think you may have that may impact your online learning. Examples might include vision (including color-blindness, challenges with reading screens / blue light), hearing, learning, attention, mental, or physical disabilities.