HealthHIV/NASHP PrEP Learning Series Application

Introduction and Team Members

Thank you for your interest in the HealthHIV/NASHP Policy Learning Series for Medicaid and Public Health Officials: Leveraging Pre-Exposure Prophylaxis (PrEP) Programs to End New Cases of HIV. This online application consists of two pages:

Page 1: Introduction and Team Members
Page 2: Questions

Please contact Lyndsay Sanborn (lsanborn@nashp.org) if you have any questions about the application process.

While we strongly encourage you to complete this application online, we will consider applications submitted via email (Word or PDF documents only). If you prefer to email your application, please submit completed applications to Erin Kim (ekim@nashp.org).

Part 1: Team Members

Teams must include representation from state Medicaid and public health agencies. If senior leadership from either agency is not directly participating in the learning series, please indicate their support of your participation when answering the questions on the following page. Additional team members from other state and local agencies may be added at the team’s discretion, including an additional team lead representing a jurisdiction’s public health department.

Question Title

* 1. State/Jurisdiction:

Core Team Members

Question Title

* 2. State Medicaid Agency Team Lead

Name

Title and Organization

Email Address

Question Title

* 3. State Public Health Agency Team Lead

Name

Title and Organization

Email Address

Optional Team Members

Question Title

* 4. Jurisdiction Public Health Department Team Lead

Name

Title and Organization

Email Address

Question Title

* 1. State/Jurisdiction:

Question Title

* 2. State Medicaid Agency Team Lead

Question Title

* 3. State Public Health Agency Team Lead

Question Title

* 4. Jurisdiction Public Health Department Team Lead

Question Title

* 5. Additional Team Members (Please include the Name, Title/Organization, and Email Address for each additional team member.)