MEMBERSHIP APPLICATION
FALL 2017
or apply at:
Applications are accepted annually in the late fall. MHAC will appoint new members to a three year term and MHAC advisors for a one year term.
Please indicate what type of application you are applying for:
☐ MHAC Member ☐MHAC Advisor
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 and II. Demographic information will be used to ensure the body is diverse across expertise and identities, and reflective of the epidemic.
Confidentiality:The information provided on this application will be held in confidence by the membership committee of MHAC. MHAC strives to maintain a diverse membership that represents those infected and affected by HIV in Michigan. While applicants may choose not to provide certain information, applications will be scored based on the information provided.
PERSONAL INFORMATION
Full Name:Click here to enter text.
Mailing Address:Click here to enter text.
City:Click here to enter text. / State: Click here to enter text. / ZIP Code: Click here to enter text.
Primary Phone:Click here to enter text.
☐ Cell? / Secondary phone:Click here to enter text.
☐ Cell? / Email: Click here to enter text.
Employer:Click here to enter text. / City:Click here to enter text. / State:Click here to enter text.
EMERGENCY CONTACT INFORMATION
Name of person to contact in case of emergency:Click here to enter text.
Relationship to applicant: Click here to enter text.
Primary phone:☐ / Secondary phone:☐ / Email:☐
DEMOGRAPHIC INFORMATION
Age Range:
☐ 14-19 years☐40-49 years
☐ 20-24 years ☐50-59 years
☐ 25-29 years ☐ > 60 years
☐ 30-39 years / Gender:
☐Male
☐Female
☐Transgender (male to female)
☐Transgender (female to male)
☐Other (please specify): Click here to enter text. / How did you hear about MHAC:
☐Co-worker
☐Friend
☐Media (Newspaper, radio)
☐Internet
☐Agency
☐Other (please specify): Click here to enter text.
Race:
(check all that apply)
☐American Indian or Alaskan Native
☐Asian
☐Black or African American
☐Native Hawaiian/Pacific Islander
☐White
☐Other (please specify): Click here to enter text. / Ethnicity:
(check all that apply)
☐Hispanic or Latino
☐Middle Eastern/ of Arab descent
☐Neither of the above / 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 (pop < 2,500)
HIV Status/Behavioral Category Representation:
Based on where you live and work, which best describes the area you would represent on MHAC?
Check all that apply HIV Status/Behavioral Category Representation:
☐ Person living with HIV/AIDS☐ MSM (man who has sex with men)
☐ IDU (injection drug user)/Needle sharing☐ Heterosexual partner of HIV+, IDU or MSM
☐ Sex worker (current or past)☐ Bisexual
☐ Other (please list): Click here to enter text
25% of MHAC seats are set aside for persons living with HIV/AIDS
*Representation is defined as “living in the skin.”Please place a mark next to words that describe you currently or in the past.
AFFILIATIONS, EXPERTISE, AND REPRESENTATIONS
Please fill in each column below by check-marking all that apply and indicate your affiliations below.
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
☐Other (please specify; i.e. substance abuse, mental health, corrections, homeless, philanthropy): Click here to enter text.
☐None / Your expertise:
(mark 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
☐Other (please list): Click here to enter text.
☐None / Communities Representation:
(mark all that apply)
☐Adolescent/young adult (≤ 24)
☐Affected person (i.e. caretaker of person living with HIV/AIDS, partner, parent)
☐Person living with HIV/AIDS
☐Heterosexual partner of HIV+, IDU or MSM
☐Injection drug user (IDU) (current or past)
☐Man who have sex with other men (MSM)
☐Sex worker (current or past)
☐Bisexual
☐Transgender
☐Other (please list): Click here to enter text.
☐None
*Representation is defined as committees with whom you have worked, volunteered or provided services
Application Part II
1)Please describe what motivates you to be a member of MHAC and what you would hope to accomplish in this role. (Use only the space provided below)
Click here to enter text.
2) Please list the knowledge, skills, and experiences that you would bring to your role on the MHAC.
Click here to enter text
Note: the knowledge, skills, and experiences don’t need to be HIV-specific, but should connect with committee work and HIV community planning.
Knowledge:Click here to enter text.
Skills:Click here to enter text.
Experience:Click here to enter text.
3)Please let us know your ability to do the following, if selected. Note to remain in good standing, members and advisors must meet participation requirements.
I can : / Yes / Maybe / No
Attend at least 3 of 4 meetings per year of the full body in Lansing (in person or via conference call) / 3 ☐ / 2 ☐ / 1 ☐
Attend at least 9 out of 12 monthly sub-committeeconference calls (1 hour each) / 3 ☐ / 2 ☐ / 1 ☐
Complete assigned committee tasks between meetings(30-60 minutes per month) / 3 ☐ / 2 ☐ / 1 ☐
Note: If you respond maybe or no, please make sure to explain your response challenges in the next section below.
4) Barriers and challenges are things we all deal with, this question helps us to know how you would deal barriers/challenges when they arise. Identify at least one barrier/challenge (e.g., 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 those barriers/challenges.
Barriers/Challenges:Click here to enter text.
What is your strategy for addressing your barriers/challenges:Click here to enter text.
5)Initiative, engagement and follow-up are all important qualities for those serving as a member on MHAC.
Please provide an honest assessment of yourself on each of these characteristics.
How frequently do you… / Usually / Sometimes / Rarely
Take on tasks and assignments willingly / 3 ☐ / 2 ☐ / 1 ☐
Stay engaged with projects to which you have committed. / 3 ☐ / 2 ☐ / 1 ☐
Complete tasks by assigned deadlines. / 3 ☐ / 2 ☐ / 1 ☐
Read and respond to emails within 3-days of receipt / 3 ☐ / 2 ☐ / 1 ☐
Speak up in a group setting / 3 ☐ / 2 ☐ / 1 ☐
6)MHAC is a body that brings together people with diverse experience and viewpoints. 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.
Click here to enter text.
AUTHORIZATION
☐ I authorize the verification of the information provided on this form.
☐ I have retained a copy of this application
Print your name here:Click here to enter text. / Date:Click here to enter text.
Submit your completed application to:
Michigan Department of Health and Human Services
Division of HIV and STD Programs
Attn: Debbie Davis
109 Michigan Avenue, 10th Floor
Lansing, MI 48913
Tel:517-241-5919 · Fax: 517-241-5922 · Email:
APPLICATIONS RECEIVED AFTER 5:00 PM onSeptember 29, 2017, WILL NOT BE CONSIDERED
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