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: ______________________________________
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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?
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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)
____________________________________________________
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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
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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.
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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.
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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:________________________
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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:
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