ELEVATE
Engage Leadership through Employment Validation and Advancing Transformation and Equity

ELEVATE Individual Application

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* 1. Please select the training you are applying for:

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* 2. First Name/ Nombre

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* 3. Last Name/ Apellido

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* 4. Which of the following best describes your CURRENT level of involvement in the HIV Workforce? (Please select one)

Employed by Ryan White HIV AIDS Program (RWHAP)

Members of Planning Bodies or Planning Councils

Members of Consumer, Community, & Patient Advisory Boards

Members of Clinical Quality Management Teams or Committees

People With HIV (PWH) aligned with a RWHAP seeking greater involvement (e.g., including individuals operating
in a volunteer or unpaid capacity)

Directors from the Boards of RWHAP

Other (please specify)

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* 5. Based on your response to the previous question; Please select the RWHAP if known.

Part: A

Part: B

Part: C

Part: D

Part: F

Not Applicable

Unknown

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* 6. Contact Information/información de contacto

Address/ Dirección

Address 2/ Dirección 2

City/ Ciudad

State/ Estado

Zip Code/ Código postal

Country /País

E-mail /Correo electrónico

Phone/ Teléfono

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* 7. Age/Edad

Under 18/Menor de 18

18-24

25-34

35-44

45-54

55-64

65+

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* 8. Gender Identity/ Identidad de género

Female/Mujer

Male/Hombre

Intersex/Intersexual

FTM or Trans Man/FTM u hombre trans

MTF or Trans Woman/ MTF o mujer trans

Gender queer

Gender Non-Conforming/Genero variante o genero no conforme

Androgynous/Androgino

Two Spirit/ Dos espiritus

Prefer not to disclose/ Prefiere no contestar

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* 9. Sexual Orientation/ Orientación sexual

Lesbian/Lesbiana

Gay

Bisexual

Heterosexual

Queer

Questioning/En cuestionamiento

Two Spirit/ dos espíritus

Same Gender Loving/ Amante del miso género

Asexual

Pansexual

Prefer Not Disclose/ Prefiere no contestar

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* 10. Ethnicity/ Origen étnico (You may select more than one option)

White or Caucasian/Caucásico o Blanco

Black or African American/AfroAmericano

Hispanic or Latinx/Latinx O Hispano

Asian or Asian American/Asiático

American Indian or Alaska Native/ Nativo Americano o Nativo de Alaka

Native Hawaiian or other Pacific Islander/ Nativo de Hawai o de las del Pacifico

Other (please specify)

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* 11. What is your highest level of education?/ ¿Cual es tu nivel más alto de educación?

Grades 1-12 no diploma/ Grados 1-12 sin diploma

High School or equivalent/ Escuela secundaria o su equivalente

Associate degree/ Grado Asociado

Some college coursework completed/ Algunos cursos univesitarios completados

Bachelor's degree/ Grado universitario

Master's degree/ Maestria

Doctorate/ doctorado

No schooling completed/ Sin escolaridad

Other (please specify)

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* 12. HIV Status/ Estado de VIH

Positive/ Positivo

Negative/ Negativo

Unknown/ No sabe

Undeclared/No declarado

Negative/not on PrEP

Negative/On PrEP

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* 13. Date of birth/ Fecha de nacimiento

Date

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* 14. Do you have access to a tablet, laptop or desktop computer to participate in online webinars and internet? / ¿Tiene usted acceso a una tablet, computadora portátil o computadora de escritorio para participar en webinars o seminarios en línea e internet? : *

Yes/ Si

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* 15. Do you have a cell phone or landline phone?/ ¿Tiene un teléfono celular o teléfono fijo?

Yes/Si

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* 16. Which of the following categories best describes your employment status?

Employed, working full-time

Employed, working part-time

Not employed, looking for work

Not employed, NOT looking for work

Retired

Disabled, not able to work

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* 17. What are some issues or discrimination that you have experienced when seeking employment? / ¿Cuáles son algunos problemas o discriminación que ha experimentado al buscar empleo?

Because I am transgender or gender non-conforming

Because I am living with HIV

Because of my race or ethnicity

Because I was homeless

Because of mental illness

Because I am gay, lesbian, or bisexual

Because of my age

Don't know

None of these

Other (please specify)

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* 18. Is there anything else you’d like us to know i.e. special accommodations, limited vision, limited mobility, special skills, diet restrictions, or interest? / ¿Hay algo más que le gustaría que supiéramos, es decir, adaptaciones especiales, visión limitada, movilidad limitada, habilidades especiales, restricciones dietéticas o interés?

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* 19. By submitting this application, I understand that, if selected, this program requires my full attendance and participation is required./ Al presentar esta solicitud, entiendo que, si soy seleccionado, este programa requiere de mi completa asistencia y participación.

Check here to agree/marca de verificación aquí para acordar

ELEVATE Engage Leadership through Employment Validation and Advancing Transformation and Equity

ELEVATE Individual Application

Question Title

* 1. Please select the training you are applying for:

Question Title

* 2. First Name/ Nombre

Question Title

* 3. Last Name/ Apellido

Question Title

* 4. Which of the following best describes your CURRENT level of involvement in the HIV Workforce? (Please select one)

Question Title

* 5. Based on your response to the previous question; Please select the RWHAP if known.

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* 6. Contact Information/información de contacto

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* 7. Age/Edad

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* 8. Gender Identity/ Identidad de género

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* 9. Sexual Orientation/ Orientación sexual

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* 10. Ethnicity/ Origen étnico (You may select more than one option)

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* 11. What is your highest level of education?/ ¿Cual es tu nivel más alto de educación?

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* 12. HIV Status/ Estado de VIH

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* 13. Date of birth/ Fecha de nacimiento

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* 14. Do you have access to a tablet, laptop or desktop computer to participate in online webinars and internet? / ¿Tiene usted acceso a una tablet, computadora portátil o computadora de escritorio para participar en webinars o seminarios en línea e internet? : *

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* 15. Do you have a cell phone or landline phone?/ ¿Tiene un teléfono celular o teléfono fijo?

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* 16. Which of the following categories best describes your employment status?

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* 17. What are some issues or discrimination that you have experienced when seeking employment? / ¿Cuáles son algunos problemas o discriminación que ha experimentado al buscar empleo?

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* 19. By submitting this application, I understand that, if selected, this program requires my full attendance and participation is required./ Al presentar esta solicitud, entiendo que, si soy seleccionado, este programa requiere de mi completa asistencia y participación.

ELEVATE
Engage Leadership through Employment Validation and Advancing Transformation and Equity