CFHPC Full Membership Application (Estimated time to complete: 15 minutes)

The Central Florida HIV Planning Council is an integrated planning and advisory body to plan the organization and delivery of services provided under Part A and Part B of the Ryan White Treatment Extension Act of 2009.
Our Mission:
To improve the quality of life for individuals with HIV by responding to their existing and emerging needs and to provide educational and behavioral strategies to targeted populations, to reduce and prevent the spread of HIV.
Our Vision:
To ensure a quality continuum of care for all individuals and families infected with, affected by and at risk for HIV disease.

HIV Planning Council Committees (please read)

Service Systems Planning & Quality: Responsible for overseeing and making improvements to the system of care from prevention to viral suppression, updating Standards of Care, assessing the efficiency of the Administrative Mechanism, monitoring of performance for clinical quality management activities, and coordinating with federal recipients.

This Committee is also responsible for the coordination of integrated planning, the annual Needs Assessment, special studies and town halls, reviewing data and management of data presentation, oversight of the PSRA process, monitoring of expenditures, and approval of reallocations across service categories.

Membership & Engagement: Responsible for developing marketing and recruitment strategies, maintaining social media and website, providing public information and education, and coordinating community events and activities. This committee is also responsible for developing marketing and recruitment strategies, maintaining social media and website, providing public information and education, and coordinating community events and activities.

The Application Process

Once you complete this application (be sure to e-sign the Statement of Member Commitment) and the Central Florida HIV Planning Council Information Sheet, then click “Submit”.

• Once received, your application will be reviewed to ensure it is complete. We will send an e-mail to confirm that we received the application.
• You will need to attend a committee meeting or the Ryan White Community Meeting. Please see the calendar for our meeting schedule. 
• After attending the two meetings, as mentioned above, an interview will be scheduled.
• Your application will then be added to the pool of applicants.
• At each monthly Membership Committee meeting, the membership profile of the Planning Council is reviewed. If new members are needed, the committee will review all of the current applications.
• If your application is chosen, you will be contacted to confirm that you wish to participate. If you agree, you will be recommended to the Orange County Chief Elected Official (CEO) for appointment to the Planning Council. Generally, it takes about one to two months for the process to be completed after the interview. You will also be encouraged to take part in Planning Council activities. Once appointed you will be required to attend orientation.
• We will keep you updated on the status of your application

Contact the Central Florida HIV Planning Council Support Team

Phone: (407) 835-0906
Fax: (407) 835-0144

Directions

Please review the first page before completing this application and be sure to sign the Statement of Member Commitment and the Planning Council Information Sheet.

All information in this application is confidential. It is seen only by the Planning Council Support staff and, as needed, by members of the Membership Committee and/or the Executive Committee during the application selection process.

- Step 1 of 5

Associate Member Online Application

This should take about 15 minutes.

Contact Information

Name *

First

Last

Pronouns (example: she/her/hers, he/him/his, they/them/theirs)

Birthday (month/day/year) *

Address *

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Email *

Primary Phone *

Alternative Phone

Preferred way to be contacted between 9:00 AM and 5:00 PM? *

• Home Phone
• Alternate Phone
• Email

May we add you to our email list to receive weekly Planning Council updates?

• Yes
• No

Would you like a current Planning Council member to contact you with more information on the CFHPC?

• Yes
• No

Were you referred by anyone? If, yes please list their name below:

Statement of Member Commitment

Statement of Member Commitment- If selected as a member of the Planning Council, I will commit to the following: *

• I confirm that, to the best of my ability, I am able to attend the regularly scheduled monthly Planning Council meetings. I will notify Planning Council Support in advance if I am unable to attend a meeting. If you are not able to attend the monthly Council meeting on a regular basis, you cannot be considered for Planning Council membership.
• I understand that membership on the Planning Council is a three-year commitment. I have considered my personal and professional commitments and do not foresee them as a barrier to my full participation on the Planning Council.
• I agree to abide by the Bylaws, Rules of Conduct, and policies and procedures of the Planning Council.
• I understand I will need to prepare for meetings by carefully reading all pre-distributed materials.
• I understand that when I make recommendations and/or decisions; I agree to consider the HIV community as a whole, rather than just special interests or my personal perspectives.
• I agree to disclose any conflicts of interest I Amy have relative to issues that come before the Council and/or Committees.
• I understand that Planning Council members are responsible for the recruitment of new members and members are encouraged to participate in outreach events.
• I agree to disclose any arrest and the resulting disposition of that arrest to the Planning Council, while a member of the Planning Council. Failure to promptly disclose the above information can lead to dismissal from the Planning Council.
• I certify that all statements and representations made in this application are true and correct.
• I understand that, if denied recommendation for appointment, no reason for denial will be given.

Statement of Member Commitment (please type your first and last name as your e-signature before moving to the next section)

E-signature *

Please type your first and last name as your signature.

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Demographics

Gender *

• Female
• Male
• Transgender (M to F)
• Transgender (F to M)
• Nonbinary/Gender Nonconforming
• Other (please specify below)

Other

Multiple Choice

• Gay/Lesbian
• Bisexual
• Heterosexual
• MSM (Men who have sex with men)
• Person Who Injects Drugs (PWID)
• Other (please specify below)

Other

Current Age *

• 16 to 19 years
• 20 to 29 years
• 30 to 39 years
• 40 to 49 years
• 50 to 59 years
• 60+ years

Race/Ethnicity *

• White, not Hispanic or Latinx
• Black, not Hispanic or Latinx
• Asian/Pacific Islander
• Hispanic or Latinx
• American Indian/Alaska Native
• Multi-race (more than one)
• Other (please specify below)

Other

Are you currently or have you ever been a volunteer for any organization(s) *

• HIV/AIDS Organization
• Board Member
• Other Organization
• No

List Organizations and hours per week you volunteer:

Have you ever been convicted of a sex crime (examples including Lewd or Lascivious acts, Sexual Battery and Rape, Unlawful Sex with a minor)? *

• Yes
• No

Or a 1st degree felony involving violence? *

• Yes
• No

Describe why you wish to become a member of the Planning Council: *

What skills, abilities and/or experience do you have that can be helpful to the Council? *

• Life Experience
• Planning Experience
• Rules/Policy Development
• Education/Training Experience
• Budgeting/Financial Planning
• Other (please describe below)

Other

What languages do you speak? *

• English
• Spanish
• Haitian Creole
• Other (please specify below)

Other

Please indicate the committee that you would like to join: *

• Service Systems Planning & Quality
• Membership & Engagement

Can we assist you with any special accommodation (such as transportation assistance, wheelchair accessibility, or translation services) to help you participate fully on the Council? If yes, please specify. *

Do you have any dietary restrictions/needs for meals served at meetings? If yes, please specify. *

Other comments you would like to share:

Federally Mandated Seats

The Planning Council is federally required to have one representative for all of the categories below. It is perfectly fine if none of these apply to you.

Please check ALL federally mandated categories that you are qualified to represent: *

• Healthcare Providers, including FQHC (Federally Qualified Health Center)
• Community Based Organizations serving affected populations/AIDS Service Organizations
• Social Service Providers, including housing and homeless services providers
• Mental Health Providers
• Substance Use Providers
• Local Public Health Agencies
• Hospital Planning Agencies or Health Care Planning Agencies
• Affected Communities including PWH (People with HIV) and historically underserved groups of subpopulations
• Non-Elected Community Leaders
• State Medicaid Agency
• State Agency Administering the Part B Program
• Part D, or if none are operating in the area, representatives of area organizations with a history of serving children, youth and families living with HIV
• HIV/AIDS Treatment Modernization Act Grantees under Part C
• Other Federal HIV Programs (includes HIV Prevention programs)
• Representatives of/or formerly Incarcerated PWH (release date must be within the past three years, but if you were living with HIV while incarcerated within the last several years please check anyway)
• None of these apply to me

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Conflict of Interest Disclosure

A conflict of interest in an actual or perceived interest in an action that will result or has the appearance of resulting in personal, organizational, or professional gain (i.e., members who serve as director, trustee, board member, salaried employee, subcontractor, or immediate family member*), or otherwise materially benefit from association with any agency receiving or seeking Ryan White Part A, Part B, Part C, Part D, and/or Part F funding is deemed to have an “interest” in said agency or agencies. Conflict of Interest does not refer to PWH whose sole relationship to a Ryan White Part A, Part B, Part C, Part D, and/or Part F funded provider is as a client or serving as an uncompensated volunteer.

I am or have been affiliated within the last six (6) months with the following organization(s) *

If this does not apply to you, then please type "N/A")

The position at the above organization(s) that I held was: *

If this does not apply to you, then please type "N/A")

Please indicate the dates that you have been affiliated with this organization(s) (ex. from July 2022 to February 2023) *

If this does not apply to you, then please type "N/A"

Immediate Family Member Conflict

Orange County Goverment defines an immediate family members as the following: father, mother, son, daughter, husband, wife, brother, sister, mother-in-law, father-in-law, son-in-law, or daughter-in-law

My immediate family member is or has been affiliated within the last six (6) months with the following organization(s) (copy) *

If this does not apply to you, then please type "N/A")

The position at the above organization(s) that my immediate family member holds/held: *

If this does not apply to you, then please type "N/A")

Please indicate the dates that your immediate family member has been affiliated with this organization(s) (ex. from July 2022 to February 2023) *

If this does not apply to you, then please type "N/A"

Please select one: *

• I DO NOT have an ACTUAL or PERCEIVED Conflict of Interest in any of the following Service Categories
• I DO have an ACTUAL OR PERCEIVED Conflict of Interest in the following Service Categories listed below:

Actual Conflicts- Core Medical Services

• Outpatient Ambulatory Health Services (OAHS)
• AIDS Pharmaceutical Assistance
• Oral Health Services
• Early Intervention Services (EIS)
• Health Insurance Premium Assistance
• Medical Case Management
• Mental Health Services
• Medical Nutrition Services

Perceived Conflicts- Core Medical Services

• Outpatient Ambulatory Health Services (OAHS)
• AIDS Pharmaceutical Assistance
• Oral Health Services
• Early Intervention Services (EIS)
• Health Insurance Premium Assistance
• Medical Case Management
• Mental Health Services
• Medical Nutrition Services

Actual Conflicts- Support Services

• Substance Abuse Services
• Non-Medical Case Management
• Food Bank/Home Delivered Meals
• Housing Services
• Psychosocial Support (Peers)
• Medical Transportation
• Emergency Financial Assistance
• Referral for Health Care and Support Services

Perceived Conflicts- Support Services

• Substance Abuse Services
• Non-Medical Case Management
• Food Bank/Home Delivered Meals
• Housing Services
• Psychosocial Support (Peers)
• Medical Transportation
• Emergency Financial Assistance
• Referral for Health Care and Support Services

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Planning Council Information Sheet

NOTE: The HIV transmission categories on this form are those used by the Centers for Disease Control and Prevention (CDC) for HIV and AIDS reporting and monitoring. The information you provide on this form will be compared in aggregate to the epidemiology of the Orlando Service Area (OSA) to determine the reflectiveness of the Planning Council to that of the disease in the OSA. Please select the category that closely identifies your method of infection. The information disclosed in this attachment will be held in the strictest of confidence as required by Federal and State regulations; only Planning Council Support Staff shall have access. The Membership Committee will be provided this information in aggregate format to monitor the reflectiveness of the Council as a whole as well as the reflectiveness of the un-aligned consumers.

My HIV Status is:

• Positive
• Negative

If yes, please list age at diagnosis:

Please select one:

• I DO self-identify* as a Person with HIV (PWH)
• I DO NOT self-identify* as a Person with HIV (PWH)

* Self-identify refers to publicly disclosing your status

The Planning Council is required to track the mode of HIV transmission for Planning Council Members who are positive. Please check the mode of transmission through which you contracted the disease.

• Men who have sex with men (MSM)
• Person Who Injects Drugs (PWID)
• MSM/PWID
• Heterosexual
• Hemophilia
• Blood transfusion
• Perinatal
• Unknown/Not Reported
• Do not wish to disclose

Transportation Assistance

Applicants who wish to be counted as a client eligible to receive transportation assistance must provide Planning Council Support with documentation of their HIV status (ie. a physician letter, lab results, etc.). Applicants should bring this documentation to their scheduled interview.

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CFHPC Rules of Conduct

Per CFHPC polices and procedures the Rules of Conduct are the minimum standards for all Planning Council Members and Associate Members are expected to follow when completing Planning Council activities and to provide guidance when working with other stakeholders, the general public and each other.

Please review the Rules of Conduct and sign to indicate acknowledgement. *

• The Planning Council operates under the current approved Bylaws and uses Robert’s Rules of Order to conduct meetings.
• Members and Associate Members shall treat everyone with respect at all times.
• Members and Associate Members shall declare their Conflict of Interest at the beginning of each meeting.
• The Chair shall establish procedures for discussion.
• Members and Associate Members shall accept and abide by the agreed-upon process for decision-making and shall accept and abide by the decisions made unless the decision has been rescinded or reversed by procedures utilizing Robert’s Rules of Order.
• Members and Associate Members shall behave in a manner that reflects their responsibility to represent the Planning Council during business meetings and when representing the Council in public.
• Members and Associate Members shall accept and follow the Council’s policies and procedures.
• Members and Associate Members shall take positive responsibility for helping to prevent and resolve conflicts within the group.
• Members and Associate Members shall refrain from conduct that is deemed detrimental to the mission of the Council and from jeopardizing the safety of fellow members and Associate Members.
• Members and Associate Members shall accept shared responsibility for determining the highest priority needs for services by using data and shall use the agreed upon process for determining priorities and allocating resources.
• Members and Associate Members who feel they cannot support and adhere to the mission of the Planning Council should reconsider their membership on the Council.
• Members and Associate Members shall take responsibility not only for following these Rules of Conduct, but also for speaking out to assure that all Planning Council members and Associate Members follow them.
• Members and Associate Members shall ensure that each matter is dealt with in a fair, equitable, impartial and just manner based on what is in the best interest of the Persons with HIV (PWH) community and other vulnerable populations.
• Members and Associate Members shall not speak, write or act for the Planning Council without proper authorization from the Executive Committee or Planning Council body.
• Members and Associate Members shall prepare for, attend and participate in the meetings of the Planning Council and Committees to which appointment has been accepted.
• Members and Associate Members shall comply with all local, state, and federal laws as they pertain to criminal activities. Members and Associate Members shall refrain from engaging in individual or group conduct that is violent, abusive, indecent, unreasonably loud, or similar disorderly conduct that infringes upon the privacy, rights, or privileges of others, or disturbs the peace or the orderly process of meetings.
• Members and Associate Members shall value and respect the diversity of the Council.
• Members and Associate Members shall carry out their duties and responsibilities with due regard to the need to promote equality of opportunity for all people, regardless of their gender, race, disability, sexual orientation, gender identification, age or religion, and show respect and consideration for others.

Planning Council Members must never: *

• Take improper advantage of their position.
• Make improper use of information they have obtained.
• Disclose confidential information.
• Behave in a manner that will reflect poorly on the Planning Council.

Statement of Zero Tolerance

It is the intent of the Principal’s Office of the Central Florida HIV Planning Council to provide a safe environment, and to prevent abusive conduct in any form. The Principal’s Office has zero tolerance for direct, conditional, or veiled acts of violence or threats of harm. Members or associate members found in violation of the Principal’s Office policies will be subject to immediate discharge from the premise of the Principal’s Office.

E-Signature *

Please type your first and last name as your signature. By signing I acknowledge that I have read and agree to the CFHPC Rules of Conduct.

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