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Nashville TGA Planning Council

Application for Membership

To help us process your membership application, please provide all of the information requested. Enter
N/A (not applicable) where appropriate. Please type or print clearly. If you need assistance filling out this
application, please contact the planning council support office at 615-340-5623. Before completing your
form you may wish to read the overview of the Planning Council on pages 8 & 9.

Please email or mail your completed application to:

Trevor Henderson.
Ryan White Program,
311 23rd Avenue North,
Nashville, TN, 37203

Page 1 & 2 of this form are considered public record. All other pages and their content are
considered confidential. All other pages are only seen by the Planning Council Support staff,
and as needed, by members of the Membership Committee and/or the Executive Committee
during the member’s selection process.

Part 1: Contact Information

Name_________________________________________________________________________

Home
Address___________________________________________________________________

City_______________________________________ State__________ Zip Code_____________

Home Phone Number_____________________ Alternate Phone Number___________________

I am a resident of which County:

… Cannon … Cheatham … Davidson … Dickson … Hickman … Macon … Robertson

… Rutherford … Smith … Sumner … Trousdale … Williamson … Wilson … Other

Email Address ________________________________________________________________

Preferred way to be contacted between 8.00am and 4.30pm?

… Home Phone … Alternate Phone … Email

May we add you to our email list? … Yes … No

I have read the Statement of Member Commitment, Conflict of Interest Statement and the Terms of
Participation and fully understand them. I hereby agree to fulfill my duties as a Planning Council
Member as explained therein.
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Signature:__________________________________________________ Date: ______ / _______ / ___________
 Nashville TGA Planning Council
Application for Membership

Biography
Please provide us with a brief description of yourself, your experience, education and in what ways you
feel that you can contribute something to this program.
Name:____________________________________________________________________________

Current Job/Position: ___________________________________________________________________

Educational background/If any(starting with most recent) :

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Professional/Volunteer/Work Experience/ If any (starting with most recent):
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What skills or knowledge do you feel you can bring to the Planning Council?:
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What experience do you have with the HIV/AIDS community?:
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 Nashville TGA Planning Council
Application for Membership

Part 3: Personal Information

For the questions below, please check for each category with which you most easily identify. Feel
free to include any additional information that you use to describe yourself on the ‘other’ lines
provided. Your responses will be kept CONFIDENTIAL and will only be available to Planning
Council Support staff, and as needed, by members of the Membership Committee and/or the
Executive Committee during the member’s selection process.

A. I am … Male … Female … Transgender … Other _________________

B. My age range is … 19 or under … 20-29 … 30-39 … 40-44

… 45-49 … 50-59 … 60+

C. My sexual orientation/preference is … Heterosexual … Gay/Lesbian

… Bisexual

D. I am a person living with HIV/AIDS … Yes … No

If ‘Yes’, as a member of the council are you willing to openly (publicly) self-identify as a person
living with HIV/AIDS?
… Yes … No

Additional Comments:
_______________________________________________________________________________

E. My race/ethnicity is:

… Black, not Hispanic … White, not Hispanic … Hispanic

… American Indian/Alaska Native … Asian/Pacific Islander … Multi-race

… Other (please specify) :____________________________________________

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 Nashville TGA Planning Council
Application for Membership

F. As a planning council member, which of the following groups do you officially

represent? (Check all that apply)

… Health Care Providers … Community Organization serving those affected by HIV/AIDS

… Homeless services … Hospital Planning Agency

… Tenncare Administration … Agency Administrating Ryan White Part B

… Mental Health … Ex-offender population

… Injection drug users … People with a history of substance use/abuse

… Hispanic/Latinos … Men of color who have sex with men

… Youth, Woman and Children living with HIV. … African American Women

… Heterosexuals … Gay, Transgender, Bisexual

… Social services provider … Local Public Health Agency

… Non-elected community leader

… People living with HIV/AIDS and co-infected with Hepatitis B and/or C

… AETC … HOPWA … SPNS (Grantees under other Federal HIV programs)

Are you a consumer of HIV/AIDS services either for yourself or for minors in your care?

… Yes … No

If ‘Yes’, are you employed by, or have you any financial interest in, an agency providing
these or other HIV/AIDS related services? (Volunteering is not classed as employment)

… Yes … No

If you are unsure about your answer to this question please call the Planning Council Support
Office. (615) 340-5623

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 Nashville TGA Planning Council
Application for Membership

Conflict of Interest Statement

The planning council may not be direction involved in the administration of the
grant. The planning council may not designate (or otherwise be involved with the
selection of) particular entities as recipients of any of the amounts provided in the
grant.* An individual may serve on the planning only if the individual agrees that, if
the individual has a financial interest in an entity, if the individual is an employee of
a public or private entity, or if the individual is a member of a public or private
organization, and such entity or organization is seeking amounts from a grant under
2601(a), the individual will not, with respect to the purpose for which the entity
seeks such amounts, participate in the process of selecting entities to receive such
amounts for such purpose.**

Conflict of Interest Disclosure

Please tell us of any conflicts of interest that you may have that relate to the above
legislation:

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*Ryan White Act Sec. 2602(b)(5)(A)

** Ryan White Act Sec. 2602(b)(5)(B)

(If you are unsure about the above statement please contact our office)

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 Nashville TGA Planning Council
Application for Membership

Nashville TGA Planning Council Terms of Participation

Individual commitment
™ A PC member will only represent the PC with prior and express permission of the Chair or the 
MPHD Community Liaison. 
™ A PC member accepts that membership requires: 
o Focusing on the greater good of the community regardless of personal concerns or 
affiliations 
o Participating in training required by regulation or as deemed appropriate and necessary 
by the Chair or MPHD  
o Committing  to attending all scheduled and called meetings insofar as possible 
ƒ  Known  limitations for participation must be explained to the MPHD 
Community Liaison as part of application to membership 
ƒ Unexpected or scheduled conflicts should be shared with the MPHD 
Community Liaison as they arise 
o Committing to complete assignments from the Chair or the MPHD Community Liaison to 
be prepared for scheduled and called meetings 
o Embracing the commitment of the PC to include and value the diversity of groups, 
persons, and views of the community 
o Supporting PC decisions as made for the greater good of the community, and/or for 
persons at risk of HIV/AIDS, and /or for the treatment and care of those infected or 
affected by HIV/AIDS. 

Confidentiality
™ While there may be circumstances in which it may be appropriate to explain PC deliberations or 
decisions outside the PC, PC members agree to focus on issues and views expressed, avoiding 
identifying personalities and persons 
™ With the exception of those PLWHA who have agreed to be publicly identified as PLWHA, no PC 
member will disclose the HIV status of any other member, even if anyone who is not publicly 
identified as a PLWHA discloses HIV status within the PC .  

Group Commitment
™ Each participant will be treated with respect 
™ Each participant will recognize and endeavor to acknowledge that each other  participant brings a 
wealth of  experience, knowledge, and commitment  that provides valuable resources to The PC 
™ However strongly or passionately participants’ views may be expressed, the  focus will be on 
issues; all agree to make every effort to avoid personality conflict and personal discord  
™ While votes will need to be taken, the PC will endeavor to reach consensus prior to voting. 

I have read the above (or have gone over it in detail with the Community Liaison); I understand the above;
I agree to the above.

Signed: Date:

______________________________________________________________________________________

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 Nashville TGA Planning Council
Application for Membership

Statement of Member Commitment

Planning Council and committee members are expected to abide by the

Council’s terms of participation. Below are the interim by-laws that outline the
code of conduct. Please read the code of conduct before completing and
submitting this membership application.

• I confirm that I am able to attend the regularly scheduled Planning Council

meeting (monthly meetings, times to be decided). 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 initially a two-

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, policies and terms of participation of the

Planning Council.

Please sign to verify that you have read and understood the above statement.

Signature:________________________________________ Date: _____ / _____ / ________

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 Nashville TGA Planning Council
Application for Membership

Information for Prospective Planning Council Members

The Ryan White HIV/AIDS Treatment Modernization Act is a federal law that provides
funds to help pay for medical and support services for people living with HIV/AIDS who
cannot pay for the care they need.

When the Ryan White Act was reauthorized in December of 2006, it made possible the
funding of five new metropolitan areas with high rates of HIV and AIDS. This is the first
time in a decade that new areas have received funding under Part A of the Act. The
Nashville Transitional Grant Area (NTGA) is one of the five new areas. The NTGA
received its first Part A funding in April of 2007, with very little planning time.

A hallmark of Ryan White is its focus on community planning and decision making.
Ryan White Planning Councils are decision-making – not advisory – bodies that play a
critical role in helping the TGA make the best possible use of Ryan White Part A funds to
provide medical and supportive services to people living with HIV and AIDS who
otherwise would not have access to comprehensive care.

The NTGA is working to establish a Ryan White Planning Council to ensure an inclusive
planning and decision-making process for our program. The Ryan White Planning
Council is a community group of people concerned about HIV/AIDS that will be
appointed by the Mayor to plan the organization and delivery of Ryan White services
funded under Part A. Its job is to help ensure a system of care that best meets the needs of
people living with HIV and AIDS throughout the NTGA, which includes Cannon,
Cheatham, Davidson, Dickson, Hickman, Macon, Robertson, Rutherford, Smith, Sumner,
Trousdale, Williamson, Wilson counties.

The Planning Council must include people representing a wide range of agencies,
interests, and expertise. We need each Council member to be a caring, dedicated
volunteer carefully selected to reflect the diversity of our community. Members represent
the general public, HIV-positive individuals, Part A service providers, and other health
and social service organizations. One-third of the members must be consumers of Ryan
White services who are not members of the Board or staff of a funded service provider.

Becoming a Council member is a great way to help those in our community who are
living with HIV. The Council needs dedicated people who can serve as both
compassionate HIV advocates and thoughtful health care planners. Sometimes the
decisions can be tough to make, but the experience is always rewarding.

Planning Council members work together to identify the care needs and service gaps of
people living with HIV/AIDS. The Council then determines which services are of the
highest priority, and how much Part A funding should be committed to each service.
Council members also play a role in reviewing the quality and outcomes of the services

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provided, and improving the system of care. The Planning Council only makes decisions
about service categories — we do not directly fund or contract with any agency to
provide client services. Contracts with service providers are established and maintained
by the County Department of Public Health.

Planning Council members are appointed for 2-year terms. Members commit four to six
hours per month to attend meetings, and additional time as needed to review documents
and/or data. Each member will be expected to attend monthly Planning Council meetings
and participate actively in at least one committee. No prior experience is necessary —
we’ll provide the training you’ll need and guide you during your first months on the
Council.

Roles and Responsibilities of Planning Councils

As a member of the Ryan White Planning Council, you will participate in a number of
important discussions and decisions. Here are some of the Council’s most important
responsibilities:

• Needs Assessment: Obtain information about the needs of PLWH, identify current
resources available to meet those needs, and determine what gaps in care exist.

• Comprehensive Planning: Develop the roadmap or vision and a three-year plan for the
HIV service delivery system in the TGA.

• Priority Setting: Decide which HIV/AIDS services are the most needed and important
for people living with HIV/AIDS in your TGA, based on needs assessment and other data
and establish priorities.

• Resource Allocation: Decide how much funding will be provided for each of the
prioritized service categories, considering costs per client and what other funding streams
are available to help support those services.

• Service Coordination and Coordinated Planning: Help avoid duplication in spending

and reduce gaps in care by looking at existing funding and making sure Part A funding is
coordinated with other Ryan White programs and other services for persons living with
HIV/AIDS. Participate in the Statewide Coordinated Statement of Need process (SCSN),
in which all Ryan White programs work together on a statewide basis to assess needs.

• Assessment of the Administrative Mechanism: Assess the efficiency of the

administrative mechanism – the systems set up by the grantee – in getting Part A services
to the community.

• Evaluation of Service Effectiveness: Review information collected by the grantee and,

if desired, directly arrange to evaluate how well services funded by Part A are meeting
community needs.

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