Michigan HIV/AIDS Council Membership Application

MHAC will appoint new members to a three year term. Members serve three 3 year terms and have voting privileges.

MHAC Membership is a volunteer position. Members are expected to commit an average of 20 hours every three months to fulfill their obligation to MHAC.

Applicants are asked to complete the entire application, including Parts I, II, and III. Demographic information will be used to ensure the body is diverse across expertise and identities, and also reflective of the epidemic. Twenty-five percent (25%) of MHAC seats are set aside for persons living with HIV/AIDS.

Confidentiality: The information provided on this application will be held in confidence by the membership committee of MHAC. All material containing confidential information is shredded after a voting quarter. MHAC strives to maintain a diverse membership that represents those living with HIV/AIDS and those affected by HIV in Michigan per CDC guidelines. While applicants may choose not to provide certain information, applications will be scored based on the information provided. We encourage you to complete all questions in the application. Leaving questions unanswered, vague, or incomplete may impact your overall application score.

PART I

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* 1. Personal Information

Full Name:

Mailing Address:

City:

ZIP Code:

Email Address:

Primary Phone:

Secondary Phone:

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* 2. Preferred Pronoun:

She, Her, Hers

He, Him, His

They, Them, Theirs

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* 3. Employer Information:

Employer

City:

State:

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* 4. Person Living with HIV/AIDS?

Yes

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* 5. Age Range

18-29

30-39

40-49

50-59

60+

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* 6. Gender:

Male

Female

Transgender Person

Other (please specify)

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* 7. Race/Ethnicity

Native American or Alaskan Native

Asian

Black or African American

Native Hawaiian/Pacific Islander

White

Hispanic or Latino

Middle Eastern/Arab

Other (please specify)

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* 8. Geographic Area; based on where you live and work, which best describes the area you would represent on MHAC?

Urban (pop. > 100,000)

Metropolitan (pop. 2,500 - 100,000)

Rural (< 2,500)

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* 9. HIV Status/Personal Representation: (Check all that apply)

MSM (man who has sex with men)

IDU (injection drug user)/Shared Drug Equipment

Transactional Sex worker (current or past)

High Risk Heterosexual partner of/or HIV+, IDU or MSM

Bisexual

Lesbian

PART II

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* 10. Please describe what motivates you to be a Member of MHAC and what you would hope to accomplish in this role. (Minimum of 150 words)

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* 11. Please list the knowledge, skills, and experience that you would bring to your role on the MHAC.

Note: Knowledge, skills, and experiences don't need to be HIV specific, however, should be related to MHAC work.

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* 12. Participation Requirements. Please let us know your ability to do the following, if selected.

Note: To remain in good standing, members must meet attendance guidelines.

If you respond maybe or no, please make sure to explain your response challenges in the next section below

	Yes	Maybe	No
Attend at least 4 of 5 full body, full day meetings per year (in person or via conference call)	Attend at least 4 of 5 full body, full day meetings per year (in person or via conference call) Yes	Attend at least 4 of 5 full body, full day meetings per year (in person or via conference call) Maybe	Attend at least 4 of 5 full body, full day meetings per year (in person or via conference call) No
Attend at least 9 out of 12 monthly sub-committee conference calls (1 hour each)	Attend at least 9 out of 12 monthly sub-committee conference calls (1 hour each) Yes	Attend at least 9 out of 12 monthly sub-committee conference calls (1 hour each) Maybe	Attend at least 9 out of 12 monthly sub-committee conference calls (1 hour each) No
Complete assigned committee tasks between meetings (30-60 minutes per month)	Complete assigned committee tasks between meetings (30-60 minutes per month) Yes	Complete assigned committee tasks between meetings (30-60 minutes per month) Maybe	Complete assigned committee tasks between meetings (30-60 minutes per month) No

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* 13. Challenges are things we all deal with, this question helps us to know how you would deal with challenges when they arise. Identify at least one challenge (ex. don't own a car, other work during business hours) that might interfere with your ability to carry out the above MHAC responsibilities. Also include strategies for overcoming these challenges.

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* 14. MHAC is a body that brings together people with diverse experiences and perspectives. The abilities to compromise, listen openly and share the spotlight are key to good group dynamics. Please provide an example of when you have had to use these abilities and the result.

PART III

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* 15. How did you hear about MHAC?

Co-Worker

Friend

Social Media

Community Events/Conferences

Agency

Other (please specify)

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* 16. Please indicate your primary affiliation:
(choose one)

Academic institution

Community-based organization providing HIV prevention or care services

Community-based organization not providing HIV prevention or care services

Community health center

HIV specialty clinic

Faith-based organization

Public health department

Research organization

Tribal organization

State Employee

Adolescent/young adult (<24)

None

Other (please specify; i.e. substance use, mental health, corrections, homeless, philanthropy)

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* 17. Please indicate your expertise: (Check all that apply)

Behavioral/social sciences

Education or training

Epidemiology

Health planning

HIV prevention interventions

HIV care coordination

HIV clinical services

Homeless services

Person living with HIV/AIDS

Mental health care

Program evaluation

Adolescent/young adult (<24)

None

Other (please list)

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* 18. Please indicate the communities you represent:
(Check all that apply)

*Representation is defined as communities with whom you have worked, volunteered or provided services

Adolescent/young adult (≤ 24)

Affected person (i.e. caretaker of person living with HIV/AIDS, partner, parent)

Person living with HIV/AIDS

High Risk Heterosexual partner of HIV+, IDU or MSM

Injection drug user (IDU) (current or past/shared drug equipment)

Man who have sex with other men (MSM)

Sex worker (current or past)

Bisexual

Lesbian

Transgender

None

Other (please list)

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* 19. I authorize the verification of the information provided on this form

Yes

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* 20. Print your name here:

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* 21. Today's Date

Date:

Date

For more information please contact Community Planner, Kyra Sanders (SandersK7@michigan.gov), or PIU Program Assistant

If this application has been redistributed, printed, or shared through other platforms please mail, email, or fax completed application to PIU Program Assistant

HIV Prevention and Intervention Unit
MDHHS, Division of STD and HIV Programs
109 Michigan Avenue, 10th Floor
Lansing, MI 48933

Phone: 517-335-8148
Fax: 517-241-5922

All applications are confidential

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* 1. Personal Information

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* 2. Preferred Pronoun:

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* 3. Employer Information:

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* 4. Person Living with HIV/AIDS?

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* 5. Age Range

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* 6. Gender:

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* 7. Race/Ethnicity

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* 8. Geographic Area; based on where you live and work, which best describes the area you would represent on MHAC?

Question Title

* 9. HIV Status/Personal Representation: (Check all that apply)

Question Title

* 10. Please describe what motivates you to be a Member of MHAC and what you would hope to accomplish in this role. (Minimum of 150 words)

Question Title

* 11. Please list the knowledge, skills, and experience that you would bring to your role on the MHAC.Note: Knowledge, skills, and experiences don't need to be HIV specific, however, should be related to MHAC work.

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* 12. Participation Requirements. Please let us know your ability to do the following, if selected. Note: To remain in good standing, members must meet attendance guidelines.*If you respond maybe or no, please make sure to explain your response challenges in the next section below*

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* 14. MHAC is a body that brings together people with diverse experiences and perspectives. The abilities to compromise, listen openly and share the spotlight are key to good group dynamics. Please provide an example of when you have had to use these abilities and the result.

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* 15. How did you hear about MHAC?

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* 16. Please indicate your primary affiliation:(choose one)

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* 17. Please indicate your expertise: (Check all that apply)

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* 18. Please indicate the communities you represent:(Check all that apply)*Representation is defined as communities with whom you have worked, volunteered or provided services

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* 19. I authorize the verification of the information provided on this form

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* 20. Print your name here:

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* 21. Today's Date

* 11. Please list the knowledge, skills, and experience that you would bring to your role on the MHAC.

Note: Knowledge, skills, and experiences don't need to be HIV specific, however, should be related to MHAC work.

* 12. Participation Requirements. Please let us know your ability to do the following, if selected.

Note: To remain in good standing, members must meet attendance guidelines.

If you respond maybe or no, please make sure to explain your response challenges in the next section below

* 16. Please indicate your primary affiliation:
(choose one)

* 18. Please indicate the communities you represent:
(Check all that apply)

*Representation is defined as communities with whom you have worked, volunteered or provided services