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VERMONT CAG MEMBERSHIP APPLICATION

Vermont's HIV Community Advisory Group (CAG) offers input and community voices to the Vermont Department of Health (VDH), with a mission “to promote effective HIV care and prevention programs.”  VDH’s goal is to ensure the CAG reflects the diverse communities most affected by HIV in Vermont.  If an applicant becomes a CAG member, they agree to represent the needs of individuals throughout the state of Vermont, regarding HIV.

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  • MEETINGS:  CAG meets every other month, currently via the internet using the Zoom platform.

  • STIPENDS:  Stipends, plus travel and childcare reimbursement, are available to members who are not attending CAG meetings as part of their job.

  • CONFIDENTIALITY:  Your application is confidential, viewed only by the Membership Committee. However, CAG itself is a public entity.  Some CAG documents become public records and may include member names, but no personal information.

  • ASSISTANCE:  If you would like help with this form, or need it translated, please contact Vermont Department of Health at 1(800)882.2437.  

 

Fill out this application here online, and hit "Apply Now" to send it on to HIV Community Planning. You will receive an email confirmation that your application has been received. You will then receive word on your application status within approximately three weeks, depending on the availability of the CAG Membership Committee. You are welcome to contact HIV Community Planning at info@vthivcag.org to check on the status at any time.

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VERMONT HIV CAG MEMBERSHIP APPLICATION
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 ONE: YOUR AFFILIATIONS 

CAG includes members of communities affected by HIV, as well as people who help prevent HIV and who provide HIV care services. Please check any and all of the boxes below that are true for you.

I'm part of a group heavily affected by HIV:
I have professional experience in:

 TWO: YOUR MEMBERSHIP TYPE 
 

CAG has three types of members - Consumer, Provider, and Associate. Please read the three descriptions below and then check the box next to the ONE form of Membership that fits you best. You may fall in more than one category -- it's important that you tell us which membership type you want to represent on CAG.  

 

You may only choose one primary membership type:

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  • CONSUMER MEMBER: Any Vermont resident living with HIV, receiving services from a Vermont HIV service provider, or having had a diagnosis of hepatitis C, can apply to serve as a Consumer Member. Consumer Members have a critical role in making sure current consumer needs in Vermont are voiced at CAG meetings. Each Consumer Member has a vote in CAG decisions.

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  • PROVIDER MEMBER: Any individual employed at an AIDS Service Organization, Community Based Organization, or Health Care Organization that works with people living with HIV and serves Vermont residents can apply to be a Provider Member. Each organization represented may have one Provider Member, who holds the agency’s vote in CAG decisions. Provider Members are charged with ultimately voting for the needs of Vermont, and not specific agency needs.

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  • ASSOCIATE MEMBER: Any individual who supports the mission of the VT HIV CAG is able to apply as an Associate Member. If approved, they may attend all open meetings and serve on committees, but may not vote on matters before the CAG. Associate Members, at the request of a Provider or Consumer Member, may serve as a proxy vote for a voting member unable to be present.

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​🗳VOTING is limited to Consumer and Provider Members.

All provider agencies will have one voting member. A consumer might also be a staff member of, or be served by, a provider agency. Consumers have one vote each, so long as that vote does not pose a conflict of interest between representation as a consumer, and allegiance to an agency.  Read more about Conflicts of Interest below.

Check ONLY ONE box below, telling us what type of member you are applying to become:

 THREE: YOUR DEMOGRAPHICS 

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The federal agencies that fund HIV services ask states to report basic demographic data on CAG Members, to make sure states have diverse CAGs that represent the communities most affected by HIV. Please share based on your comfort:

 FOUR: YOU & CAG 

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Please answer the three questions below in two to three sentences, or short lists.

Community can mean different types of groups: The communities we live in, such as our towns, counties and state, and the communities of people you may identify as a part of, such as people living with HIV, LGBTQ people, People of Color, Sex Workers, and others. We are all members of many communities. Please think about any of these communities as you answer the following question. 

 FIVE: YOUR POTENTIAL CONFLICTS OF INTEREST 

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CAG helps advise and guide HIV Prevention & Care Services priorities and funding in Vermont. CAG does not directly oversee how HIV funds are spent. But the group's decisions do have impact on VDH funding priorities. It is important that all members disclose [tell the HIV Community Planner] about any potential Conflicts of Interest. ​

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  • A conflict of interest occurs when a CAG member is an employee, client, volunteer, or board member of an organization that may receive funds as a result of a CAG decision. This is considered a financial interest.

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  • Members with a financial interest in a decision are required to disclose (report verbally or in writing to the Community Planner) any conflicts when asked. Members will sometimes need to abstain from voting (choose not to vote) on a given issue, as a result of their financial interests. ​

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  • Other types of conflicts of interest exist, including but not limited to: benefits other than financial, preferential treatment, and family relationships among decision makers. The basic definition of a conflict is if you, or the organization you are representing, receives personal benefit or gain as a direct result of an official decision that you have participated in making.

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  • If you have questions about Conflicts of Interest please don't hesitate to ask more questions:  info@vthivcag.org

 SIX:  YOUR ACKNOWLEDGEMENTS 

Please read the statements below. Please check ALL THREE boxes to tell us that you have read each one and understand the responsibilities of the HIV CAG, and that you give permission for your application to be shared with the CAG Membership Committee.

I acknowledge that:

Thank you for your interest in Vermont's HIV Community Advisory Group. Please sign this document by entering your name in the signature box below, date it, then click the Apply Now button.  

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