Ryan White Program Quality Management Committee Application Charlotte TGA Ryan White Program Part A Quality Management Committee 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 Quality Management Committee support office at (704) 432-5271. Please email or mail your completed application to: Valetta C. Rhinehart Ryan White Program Mecklenburg Count Health Department 618 College Street Charlotte, NC 28202 (704) 432-5271 Valetta.Rhinehart@mecklenburgcountync.gov 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 Quality Management Committee Support staff during the member’s selection process. Part 1: Contact Information Name_____________________________________________________________ Home Address______________________________________________________ City ________________________________State___________ Zip Code_______ Home Phone Number ________________Alternate Phone Number____________ Email Address______________________________________________________ Preferred way to be contacted between 8.OOam and 4.3Opm? Home Phone Alternate Phone Email May we add you to our email list? Yes No I am a resident of which County: Mecklenburg Union Gaston Cabarrus Anson York I hereby agree to fulfill my duties as a Quality Committee Member as explained herein. Signature: ______________________________________ 1 Date: _______ I ________ I _____________ Ryan White Program Quality Management Committee Application Charlotte TGA Ryan White Program Part A Quality Management Committee Application for Membership Part 2. 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. Current Job/Position: ____________________________________________________ Professional/Volunteer/Work Experience/ If any (starting with most recent): What skills or knowledge do you feel you can bring to the Quality Management Committee? Do you have quality management experience? ___Yes ___No? What experience do you have with the HIV/AIDS community? 2 Ryan White Program Quality Management Committee Application Charlotte TGA Ryan White Program Part A Quality Management Committee Application for Membership Part 3: Personal Information (confidential 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 Quality Management Committee Support staff during the member’s selection process. A. l am Male Female Transgender Other B. My age range is 19 or under 20-29 30-39 40-49 C. I am a person living with HIV/AIDS Yes 50-59 60+ No If ‘Yes’, as a member of the quality committee are you willing to openly (publicly) selfidentify as a person living with HIV/AIDS? Yes No D. My race/ethnicity is: Black, not Hispanic White, not Hispanic Hispanic Native Asian/Pacific Islander Multi-race Other (please specify) ____________________________________________________ 3 American Indian/Alaska Ryan White Program Quality Management Committee Application Charlotte TGA Ryan White Program Part A Quality Management Committee Application for Membership E. As a quality management committee member, which of the following groups do you officially represent? (Check all that apply) Persons living with HIV/AIDS Health Care Providers Homeless services Mental Health Agency Persons previously incarcerated Youth, Woman and Children living with HIV Social services provider Non-elected community leader Community Organization serving those affected by HIV/AIDS Hospital Planning Agency Agency Administrating Ryan White Part B Person with a history of substance use/abuse Local Public Health Agency 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 4 Ryan White Program Quality Management Committee Application Charlotte TGA Quality Management Committee (QMC) Information for Prospective Quality Management Committee 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. The Charlotte Transitional Grant Area (CTGA) is one of the five new 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. A hallmark of Ryan White is its focus on community planning and decision making. The Ryan White Quality Management Committee is an advisory body that plays 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 Charlotte TGA is working to establish a Ryan White Quality Management Committee to ensure an inclusive planning and decision-making process for our program. The Committee’s role is to help ensure a system of care that best meets the needs of people living with HIV and AIDS throughout the Charlotte TGA, which includes Anson, Cabarrus, Gaston, Mecklenburg, Union and York (SC) counties. The Quality Management Committee must include people representing a wide range of agencies, interests, and expertise. We need each QMC member to be a caring, dedicated volunteer carefully selected to reflect the diversity of our community. Members represent the general public, consumers, Part A service providers, and other health and social service organizations. Becoming a QMC member is a great way to help those in our community who are living with HIV/AIDS. The QMC needs dedicated people who can serve as both compassionate HIV/AIDS advocates and thoughtful health care planners. Sometimes the decisions can be tough to make, but the experience is always rewarding. Quality Management Committee members work together to identify the care needs and service gaps of people living with HIV/AIDS and plays a vital role in reviewing the quality and outcomes of the services provided, and improving the system of care. Each member will be expected to attend quarterly Quality Management Committee meetings and participate actively in at least one subcommittee. We will provide the training you will need and guide you during your first months on the Committee. 5 Ryan White Program Quality Management Committee Application Roles and Responsibilities of Quality Management Committee Members As a member of the Ryan White Quality Management Committee, you will participate in a number of important discussions and decisions. Here are the Committee’s most important responsibilities: Quality Management Plan: Participate in the development, approval and implementation of a quality management plan for the Charlotte TGA. Contribute to the annual evaluation of the plan. Evaluation of Service Effectiveness: Review information collected on service delivery to evaluate how well services funded by Part A are meeting community needs. Attendance: Regular participation and attendance at the QM Committee meetings (in-person or via conference call) for the grant year. 6 Ryan White Program Quality Management Committee Application Charlotte Ryan White Program Quality Management Committee (QMC) Application for Membership Terms of Participation Individual commitment A QMC member will only represent the QMC with prior and express permission of the Chair or the Mecklenburg County Health Department Ryan White Liaison. o A QMC member accepts that membership requires: o Focusing on the greater good of the community’s bias regardless of personal concerns or affiliations o Participating in training required or as deemed appropriate and necessary by the Chair o Completion of orientation module of the QMC o Committing to attending all scheduled and called meetings insofar as possible o Embracing the commitment of the QMC to include and value the diversity of groups, persons, and views of the community o Supporting QMC 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. o Known limitations for participation must be explained to the Quality Management Committee (QMC) Community Liaison as part of application to membership o Unexpected or scheduled conflicts of interest should be shared with the QMC Community Liaison as they arise Confidentiality While there may be circumstances in which it may be appropriate to explain QMC deliberations or decisions outside the QMC, QMC members agree to focus on issues and views expressed, avoiding identifying personalities and persons With the exception of those who have agreed to be publicly identified as PLWHA, no QMC 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 QMC 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 QMC 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 QMC will endeavor to reach consensus prior to voting. I have read the above (or have gone over it in detail with the QMC Community Liaison); I understand the above; I agree to the above. Signed _________________________________________Date:________________________ 7 Ryan White Program Quality Management Committee Application Charlotte TGA Quality Management Committee Application for Membership Statement of Member Commitment Quality Management Committee and committee members are expected to abide by the Committee’s terms of participation. Below are the interim bylaws that outline the code of conduct and governance. Please read the code of conduct before completing and submitting this membership application. • I confirm that I am able to attend the regularly scheduled Quality Management Committee meeting (monthly meetings, times/day to be decided). Attendance includes either in person or conference call participation. I understand that missing more than 3 scheduled meetings in a calendar year will be viewed as grounds for dismissal from the committee. Notice of such dismissal will be presented in writing from the QMC Committee Chairperson. • I understand that membership on the Quality Management Committee is initially a one-year commitment. I have considered my personal and professional commitments and do not foresee them as a barrier to my full participation on the Quality Management Committee. • I agree to abide by the bylaws, policies and terms of participation of the Quality Management Committee. I verify that I have read and understood the above statement. I have had the opportunity to ask questions for clarification of this Statement of Member Commitment and its content. Signature:____________________________________________ Date: 8 _____ / _____ / _________