ELEVATE Engage Leadership through Employment Validation and Advancing Transformation and Equity for Organizations

ELEVATE Organization Application

Question Title

* 1. Please select from the options below which training you are applying for:

Question Title

* 2. What is the name of your organization?

Question Title

* 3. Applicant Information

Applicant Name

Organization Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

Question Title

* 4. Below, please list all of the staff names and email addresses for who will be attending the ELEVATE training. (If applicable)

Additional Staff 1

Additional Staff 2

Additional Staff 3

Additional Staff 4

Additional Staff 5

Question Title

* 5. What is the full name and email address of the community member you are partnering with for the ELEVATE program? (If applicable)

Question Title

* 6. Based on question 5; please provide the contact info for any additional community members participating in the ELEVATE training.

Name

Email Address

Name

Email Address

Name

Email Address

Question Title

* 7. How many years have you been with the organization?

Question Title

* 8. ELEVATE Organizational Self-Assessment Tool (ESAT)

This tool will help organization representatives assess organizational capacity and readiness for actualization of the guiding principles of ELEVATE before and after participation in the program.

Who is the best person at the organization to take the ELEVATE Organizational Self-Assessment Tool (ESAT)?

Question Title

* 9. Which of the following best describes your organization? (Please select one)

Ryan White HIV AIDS Program (RWHAP)

Planning Bodies or Planning Councils

Consumer, Community, & Patient Advisory Boards

Clinical Quality Management Teams or Committees

Organization that services People With HIV (PWH) but is not aligned with a RWHAP seeking greater involvement

Directors from the Boards of RWHAP

Other

Question Title

* 10. What are some issues or discrimination practices that you have observed when seeking to employ people with HIV (PWH)?

Question Title

* 11. What are the barriers that you organization has experienced when seeking employ to people with HIV (PWH)?

Question Title

* 12. Is there anything else you’d like us to know about your organization?

Question Title

* 13. By submitting this application, I understand that, if selected, this program requires my full attendance and participation is required./ Al presentar esta solicitud, entiendo que, si soy seleccionado, este programa requiere de mi completa asistencia y participación.

Check here to agree/marca de verificación aquí para acordar