Application for Health Equity Advisory & Leadership (HEAL) Council
All information you provide on this form is available to the public upon request.
Applicant Name:
(First Name) (Middle Name) (Last Name)
Applicant Address:
(Street) (City) (State) (Zip)
Day Phone: ( ) - Evening Phone: ( ) -
EMAIL:
Geographic area you or your group/network represent
Short Answer Questions:
Please attach a separate typed document answering the following three questions below. Response should be NO LONGER than two pages. If you would like to submit these answers in an alternative format (video, audio, etc.), please contact Xiaoying Chen (contact info below).
· Please share how your personal and/or professional experience has prepared you to be a champion for a community (or communities) impacted by health inequities. Please name those communities where appropriate.
· Briefly describe your experience (personal and/or professional) in advancing health equity at a community, institutional or systems level.
· Briefly list or describe the organizations, groups, or networks that you are connected to in your work to advance health equity, including your role(s) in each.
I swear that, to the best of my knowledge, the above information is correct and that I satisfy all legally prescribed qualifications for the position sought.
(Signature of Applicant) (Date)
OPTIONAL STATISTICAL INFORMATION
The following information is optional and voluntary.
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Race*:
African American / Black
American Indian / Alaska Native
Asian American
Native Hawaiian / Pacific Islander
White
Other
(*Select as many as apply)
Ethnicity:
Self-identified:
Hispanic or Latino
Not Hispanic or Latino
Gender Identity: ___ Female ___ Male
Other
Sexual Orientation:
Languages:
(Please specify)
Disability: ☐Yes ☐No
Type of disability (optional):
National Origin:
(Country of Origin or Principle Tribe)
Preferred Gender Pronoun:
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Health Equity Advisory & Leadership (HEAL) Council
Frequently Asked Questions
EMAIL, MAIL OR SUBMIT APPLICATION IN PERSON TO:
Minnesota Department of Health Center for Health Equity
Re: HEAL Application
625 Robert St. N., P.O. Box 64975
St. Paul, MN 55164-0975
Email:
Applications must be RECEIVED by September 27, 2017.
Questions? Please call Xiaoying Chen at 651-201-5822 or email her at .
If you would like to submit the answers to the short answer questions in an alternative format (video, audio, etc.), please contact Xiaoying Chen at the contact above.
Minnesota Department of Health
Center for Health Equity
PO Box 64975
St. Paul, MN 55164-0975
651-201-5813
8/9/17
To obtain this information in a different format, call the MDH Office of Inclusion at 651-201-4089 or 651-201-4175 or email .
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