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Area 15 Comprehensive Planning Network (CPN) Membership Application

SERVING INDIAN RIVER, MARTIN, OKEECHOBEE, AND ST. LUCIE COUNTIES


Address: Florida Department of Health in St. Lucie County, 5150 NW Milner Drive, Port Saint Lucie, FL 34983


Phone: 772-584-9141 | E-Mail: planning@hcsef.org | Fax: 561-844-3310 Website: Area15CPN.org

Applicant Information

To help the Consortia support staff and the Membership Committee process your membership application, please provide all of the information requested and type or print clearly.

Multi-line address

Business Information

Business Address

Tell us about yourself

Your responses will be kept CONFIDENTIAL and available only to the Consortia support staff and the Membership Committee.

Racial or Ethnic Group
Gender

OPTIONAL

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f you are a person living with HIV, are you willing to self-identify as such for Area 15 HIV/AIDS Comprehensive Planning Network activities?*
Yes
No
Not Applicable
Please indicate if any of the following apply*

* Disclosure of HIV status is encouraged, but not required for membership.

Committee Interest (MANDATORY - Please choose only one.)

The Area 15 Comprehensive Planning Network General Body meets every two months (currently on the 4th Tuesday) via Zoom from 11:00 AM - 12:00 PM. The Committees meet monthly (currently on the 2nd Thursday) via Zoom - the Membership Committee meets from 10:00 AM - 11:00 AM while the Evaluation Quality Assurance/Planning Committee meets from 11:00 AM - 12:00 PM.

Member Conflict of Interest Declaration

I, the undersigned hereby affirm that neither I, nor any member of my family, agency or employer: (please check applicable statement)
Will NOT benefit from business conducted by myself as a member of the AREA 15 HIV/AIDS
Will benefit from business conducted by myself as a member of the AREA 15 Comprehensive

Please type your full name

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Memorandum of Understanding Confidentiality of Client Information

The purpose of the Memorandum of Understanding is to emphasize that all information held in client records is confidential, with access governed by state and federal laws. Information which is confidential includes a client’s name, address, date of birth, medical, social, and financial data, and services received. In addition, the fact that someone has had an HIV test is confidential, whether the result of that test is positive, negative or if there is a client self-disclosure. Data collection by interview, observation or review of documents should be conducted in a setting that protects the client’s identity from unauthorized individuals.


Section 384.29, Florida Statutes, address the need for special discretion in the handling of sexually transmissible disease information. Sexually transmissible disease, by their nature, involves sensitive issues of privacy and all programs designed to deal with these diseases should afford privacy and confidentiality to the client.


Section 381.609, Florida Statutes, deals with confidentiality of HIV test results. There are penalties for violating this statute. These penalties range from disciplinary action by agency to a criminal misdemeanor.

Agency Name (if applicable)

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This information is being requested in accordance with federal regulations. The information is kept private and will not be used when considering you for membership.

AREA 15 HIV/AIDS Comprehensive Planning Network GROUND RULES

We are operating under the sunshine law and Roberts Rules of Order. This is a public meeting. Information discussed during meetings is subject to public records disclosure.

  1. One person speaks at a time; others listen and do not interrupt.

  2. Each person speaks for himself or herself, do not claim to speak for others unless you are delegated to do so.

  3. Be polite. It’s acceptable to disagree but do so respectfully. Insults and accusations are unacceptable

  4. Share group time fairly. Allow everyone a chance to speak and listen.

  5. Be open to listening to and learning from others’ viewpoints.

  6. When the Network is locked in conflict, agree to stop the agenda and brainstorm creative options.

  7. Refer to the Network’s written policy and procedures for handling conflict that cannot be resolved in a regular meeting.

  8. Allow adequate agenda time for particularly sensitive issues. Make sure that each person has time to discuss all aspects of the issue without unrealistic time constraints being imposed.

  9. Clarify who will monitor group interactions for compliance with the ground rules and agree to what happens to repeat offenders

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