TB Elimination Alliance Membership Interest Form

Thank you for your interest in the TB Elimination Alliance. Membership is reviewed quarterly in April, August and December. After your form has been reviewed, you will be contacted with next steps. Please contact tea@aapcho.org if you have any questions or concerns.

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* 1. Organization/Coalition

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

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* 2. Contact Person

Name

Email Address

Phone Number

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* 3. Secondary Contact Person

Name

Email Address

Phone Number

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* 4. Organizational Information: Please check all categories that best describe your organization.

Local/State TB Coalition

National/Professional Organization

Community Health Center

Community Based Organization

State/City/County Health Agency

Academic Institution

Other (please specify)

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* 5. Organizational Structure

Not-for-profit organization

Unincorporated association

Other (please specify)

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* 6. Month/Year Founded

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* 7. Region/State/County/City Represented

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* 8. Number of staff/members/volunteers in your organization (please specify)

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* 9. Targeted populations (please specify)

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* 10. Organizational Mission Statement

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* 11. Organizational Interest (Needs) in TB Elimination Alliance Membership (please specify)

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* 12. Organizational Activities: Briefly describe the activities of your organization (or attach descriptive material)

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* 13. Does your organization have any of the following community based LTBI/TB specific activities/programs?

LTBI/TB Advocacy

LTBI/TB Screening

LTBI/TB Treatment

LTBI/TB Patient Navigation

LTBI/TB Outreach/Education

LTBI/TB Patient Support Group

TB Vaccination

Language interpretation services for LTBI/TB service referrals

Participation in LTBI/TB state and/or federal planning groups

Translation of education materials

Other (please specify)

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* 14. Are there any LTBI/TB education/outreach materials created by your organization you would like to share?

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

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* 15. Any additional attachments you would like to share?

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

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* 16. Any additional attachments you would like to share?

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.