NAESM's CBA Program: Consultant Registration Form

CBA Consultant Registration Form

Fields marked with an asterisk (*) are required.

Contact Information

Individual's Name *

Organization/Business' Name (if applicable)

Mailing Address*

City*	State/Territory*	ZIP*

10-Digit Telephone*	10-Digit Fax

Email*

Website

Community Planning and Consulting Experience

Number of years consulting for non-profit organizations:
Number of years consulting for for-profit organizations:
Number of years consulting for health departments:
*Number of years as a member of HIV prevention community planning:*

Please list three (3) organizations that represent a diverse sampling of your consulting experience.*

Organization # 1 Name

Organization # 2 Name

Organization # 3 Name

Consultant's Education (list two highest degrees received)

Degree	Field/Major

Date	College/University/Institution

Degree	Field/Major

Date	College/University/Institution

Are there any types of organizations or topics of interest you prefer to work with?

Are there any types of organizations or topics of interest you prefer not to work with?

Areas of Practice

Select only those areas you are most familiar. Use the Specific Experience section of this form (below) to cite examples related to the checked content areas. Select all that apply.

Process Management

	Planning group selection/retention
	Conflict management
	Consensus building
	Evaluation of the planning process
	Parliamentary procedure and meeting processes

Parity, Inclusion, and Representation

	Recruiting an inclusive group
	Maintaining full/effective representation
	Cultural competency
	Diversity sensitivity

Community Needs and Resource Assessment

	Assessment strategies/data sources
	Qualitative/quantitative research methods
	Consumer/provider input
	Social network analysis
	Community resources inventories/asset mapping

Leadership Development

	Theory		Setting goals/objectives
	Human Behavior		Community awareness
	Strategies		Networks

Other Areas of Practice

Experience with Specific Populations

By Racial/Ethnic Background (check all that apply)

	American Indian/Alaskan Native/Native Hawaiian		Hispanic/Latino
	Asian/Pacific Islander		White
	Black/African American

By Risk Behavior (check all that apply)

	People Living with HIV		Men having Sex with Men (MSM)
	Intravenous Drug Users (IDU)		MSM/IDU
	Heterosexual Females		Homeless Persons
	Incarcerated Persons		Mothers-at-Risk
	Migrant Populations		Youth-at-Risk

Specific Experience

Use this space to describe your specific experience in HIV prevention community planning.*

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