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PART A NAME & CONTACT INFORMATION

A.1 Primary Contact Information

Primary Address

A.2 Mailing Address

A.3 Gender & Race

PART B: EMPLOYMENT AND VOLUNTEER EXPERIENCE

B.1. Where do you work

B.2 If you are a volunteer, do you receive any payment, including a stipend?

B.3 What are your work or volunteer responsibilities?

B.4 How long have you been working or volunteering at the organization you identified above?

B.5 Are you a member of the Board of Directors of an agency that receives Ryan White Part A funding?

B.6 Please list any certifications, licensure or relevant educational history that would benefit you in your position as a Planning Council member?

B.7 Are you aware of any potential Conflicts of Interest

(i.e., are you or a significant other a member of, employee of, or have a direct/indirect financial interest in an organization seeking/receiving Ryan White Part A funds?)

Rules of law and ethics prohibit members from participating in and voting on matters in which they may have a direct/indirect financial interest.

B.8 Please select the categories that you are qualified to represent. (Check all that apply)

PART C PERSONAL STATEMENT

Please provide a brief statement supporting your interest in becoming a Planning Council Member. Include details on qualifications, such as commitment to helping PLWHA, work or volunteer experience relevant to HIV/AIDS or health planning, leadership skills, and ability to work with a culturally diverse team. You may attach a separate page if necessary.

PART D PLANNING COUNCIL STANDING COMMITTEES

Serving on at least one Standing Committee is a requirement of Planning Council Membership. Please review descriptions of the Standing Committees listed below.

• Needs Assessment (NA)/Comprehensive Planning & Continuum of Care (CPCC): Develop and implement a Needs Assessment strategy that will provide data that guides the development of the TGA’s Continuum of Care, service needs priority setting, funding allocations, contents of grant applications and the intent and strategic direction of the Integrated HIV Prevention and Care Plan (previously known as the Comprehensive Plan). Develop the TGA’s Continuum of Care, service category Standards of Care, Service Category Definitions and define Service Category Units of Service. CPCC is tasked with coordinating the development of the Integrated HIV Prevention and Care Plan (previously known as the Comprehensive Plan), monitoring its goals and objectives, and participating in the Statewide Coordinated Statement of Need.

• Fiscal Monitoring and Reallocations (FMRA): Monitoring priorities and expenditures and recommending to the Planning Council any reallocation of funds. Requesting pertinent data and information from the Grantee/Administrative Agency to assist the Planning Council in making decisions for the priority setting among service categories and the distribution of funds to these service categories in accordance with Ryan White Legislation and HRSA Policy/Procedures.

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• Membership, Nominations and Elections (MNE): Recruiting, screening and recommending potentiaL candidates for membership to the Planning Council, tracking Planning Council Membership classifications and demographics, as well as changes in population affected by HIV/AIDS,recommending appropriate Membership classification and representation modifications, and tracking Member attendance.

D.2 Please indicate the committee(s) you would be interested in serving on.

Please note: Planning Council committees generally meet once a month. The Planning Council Co-Chairs are tasked with assigning new members to a committee. They will take your expertise and committee preference into account when making committee assignments.

PART E SIGNATURE

E.1 Signature of Applicant

I understand that I am applying for membership in the San Antonio Area HIV Health Services Planning Council. I can commit to a minimum of ten (10) hours per month to prepare for, travel to, and attend meetings of the Planning Council and its committees. I understand that full Planning Council meetings are roughly two hours in length I understand that Committee meetings are scheduled between 11:30 a.m. and 4:00 p.m. I have completed the information on this form truthfully and to the best of my knowledge.