The International Center for Equal Healthcare Access

To apply to be a non-medical field volunteer with ICEHA, please fill out the following questionnaire AND e-mail your CV to . Once you have submitted your CV and application, we will provide you with information on how to supply your letters of reference. To receive a Word version of the questionnaire, e-mail .

Name:

Date:

E-mail address:

Address:

City:

State or Province:

Zip or Postal Code:

Country:

Is this your work or home address?
Work
Home

Phone Number:

Fax Number:

Degree:

Organization:

When would be your earliest available time to participate in an overseas program?

Are there other dates later this year or next year that you would be available? When?

If your dates are flexible, how far in advance would you need to be notified in order to be able to participate?

How long is the maximum period of time you would be available to spend overseas?

Would you be comfortable in a location without electricity or running water (this is not a requirement to volunteer; you will not be sent to a location without electricity or running water unless you indicate that is something you are comfortable with)?
Yes
No

What type of HIV experience do you have (ie social worker, health educator)? Please list specific activities that you perform each week.

What is your level of experience in terms of working in the HIV field?
Less than three years
Three to seven years
Eight to ten years
More than eleven years

Mark all populations that you have experience working with.
IV Drug Users
Sex Workers
Children

Do you have experience in developing countries?
Yes
No

If so, which ones?

And for how long?

Do you speak other languages?
Yes
No

Please list all languages and level of proficiency:

Do you have a preference for a particular country or continent? Please rank.

Do you have related experience?
Yes
No

Please explain.

Would you be comfortable in a location without electricity or running water (this is not a requirement to volunteer; you will not be sent to a location without electricity or running water unless you indicate that is something you are comfortable with)?
Yes
No

How did you find out about ICEHA?
Colleague
Talk by ICEHA Staff Member
Email
Former ICEHA clinical mentor
Google
Other Website, please specify
ICEHA booth at conference, specify conference
Flyer/brochure at conference, specify conference
Article/Journal, specify publication
Other, please specify