TB Elimination Alliance Membership Interest Form

Thank you for your interest in the TB Elimination Alliance. Membership is reviewed quarterly in April, August and December. After your form has been reviewed, you will be contacted with next steps. Please contact tea@aapcho.org if you have any questions or concerns.

Question Title

1. Organization/Coalition (Required.)

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Question Title

2. Contact Person (Required.)

Name

Email Address

Phone Number

Question Title

3. Secondary Contact Person (Required.)

Name

Email Address

Phone Number

Question Title

4. Organizational Information: Please check all categories that best describe your organization. (Required.)

Local/State TB Coalition

National/Professional Organization

Community Health Center

Community Based Organization

State/City/County Health Agency

Academic Institution

Other (please specify)

Question Title

5. Organizational Structure (Required.)

Not-for-profit organization

Unincorporated association

Other (please specify)

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6. Month/Year Founded (Required.)

Question Title

7. Region/State/County/City Represented (Required.)

Question Title

8. Number of staff/members/volunteers in your organization (please specify) (Required.)

Question Title

9. Targeted populations (please specify) (Required.)

Question Title

10. Organizational Mission Statement (Required.)

Question Title

11. Organizational Interest (Needs) in TB Elimination Alliance Membership (please specify) (Required.)

Question Title

12. Organizational Activities: Briefly describe the activities of your organization (or attach descriptive material) (Required.)

Question Title

13. Does your organization have any of the following community based LTBI/TB specific activities/programs?

LTBI/TB Advocacy

LTBI/TB Screening

LTBI/TB Treatment

LTBI/TB Patient Navigation

LTBI/TB Outreach/Education

LTBI/TB Patient Support Group

TB Vaccination

Language interpretation services for LTBI/TB service referrals

Participation in LTBI/TB state and/or federal planning groups

Translation of education materials

Other (please specify)

TB Elimination Alliance Membership Interest Form

Question Title

1. Organization/Coalition (Required.)

Question Title

2. Contact Person (Required.)

Question Title

3. Secondary Contact Person (Required.)

Question Title

4. Organizational Information: Please check all categories that best describe your organization. (Required.)

Question Title

5. Organizational Structure (Required.)

Question Title

6. Month/Year Founded (Required.)

Question Title

7. Region/State/County/City Represented (Required.)

Question Title

8. Number of staff/members/volunteers in your organization (please specify) (Required.)

Question Title

9. Targeted populations (please specify) (Required.)

Question Title

10. Organizational Mission Statement (Required.)

Question Title

11. Organizational Interest (Needs) in TB Elimination Alliance Membership (please specify) (Required.)

Question Title

12. Organizational Activities: Briefly describe the activities of your organization (or attach descriptive material) (Required.)

Question Title

13. Does your organization have any of the following community based LTBI/TB specific activities/programs?

Question Title

14. Are there any LTBI/TB education/outreach materials created by your organization you would like to share?

Question Title

15. Any additional attachments you would like to share?

Question Title

16. Any additional attachments you would like to share?

TB Elimination Alliance Membership Interest Form

Question Title

* 1. Organization/Coalition (Required.)

Question Title

* 2. Contact Person (Required.)

Question Title

* 3. Secondary Contact Person (Required.)

Question Title

* 4. Organizational Information: Please check all categories that best describe your organization. (Required.)

Question Title

* 5. Organizational Structure (Required.)

Question Title

* 6. Month/Year Founded (Required.)

Question Title

* 7. Region/State/County/City Represented (Required.)

Question Title

* 8. Number of staff/members/volunteers in your organization (please specify) (Required.)

Question Title

* 9. Targeted populations (please specify) (Required.)

Question Title

* 10. Organizational Mission Statement (Required.)

Question Title

* 11. Organizational Interest (Needs) in TB Elimination Alliance Membership (please specify) (Required.)

Question Title

* 12. Organizational Activities: Briefly describe the activities of your organization (or attach descriptive material) (Required.)

Question Title

* 13. Does your organization have any of the following community based LTBI/TB specific activities/programs?

Question Title

* 14. Are there any LTBI/TB education/outreach materials created by your organization you would like to share?

Question Title

* 15. Any additional attachments you would like to share?

Question Title

* 16. Any additional attachments you would like to share?

1. Organization/Coalition (Required.)

2. Contact Person (Required.)

3. Secondary Contact Person (Required.)

4. Organizational Information: Please check all categories that best describe your organization. (Required.)

5. Organizational Structure (Required.)

6. Month/Year Founded (Required.)

7. Region/State/County/City Represented (Required.)

8. Number of staff/members/volunteers in your organization (please specify) (Required.)

9. Targeted populations (please specify) (Required.)

10. Organizational Mission Statement (Required.)

11. Organizational Interest (Needs) in TB Elimination Alliance Membership (please specify) (Required.)

12. Organizational Activities: Briefly describe the activities of your organization (or attach descriptive material) (Required.)

13. Does your organization have any of the following community based LTBI/TB specific activities/programs?

14. Are there any LTBI/TB education/outreach materials created by your organization you would like to share?

15. Any additional attachments you would like to share?

16. Any additional attachments you would like to share?