INTERESTED IN JOINING a STEERING COMMITTEE? Please complete this inquiry form below. Steering Committee Inquiry Name(Required) First Last Name of Organization or Community Representing(Required) Type of Organization or Individual(Required) Community-based organization Behavioral health organization Substance use treatment, prevention, or recovery organization Community member Contact Phone(Required)Email(Required) Enter Email Confirm Email URL of website for organization, if applicable Communities You ServeDo you or your organization serve or identify with a specific Native Hawaiians and/or Pacific Islander ethnic group? Please check off all cultural communities that your organization serves or if you are answering as an individual, please check all ethnicities do you identify with. Kānaka Maoli (Native Hawaiian) Chamorro/CHamoru Chuukese Fijian I-Kiribati Kosraean Marshallese Palauan/Belauan Pohnpeian Samoan Tahitian Tokelauan Tongan Yapese Other Pacific Islander (please specify below) If other above, please specify here. o you or your organization serve or identify with a specific Asian American ethnic group? Please check off all cultural communities that your organization serves or if you are answering as an individual, please check all ethnicities do you identify with. Bangladeshi Bhutanese Bruneian Burmese Cambodian Chinese Filipino Hmong Indian Indonesian Japanese Korean Laotian Malaysian Maldivian Mien Nepali Okinawan Pakastani Singaporean Sri Lankin Thai Tibetan Timorese Vietnamese Other Asian American (please specify below) If other above, please specify below. Regional Framework. The ‘Ohana CoE is creating and developing a regional framework with the understanding that Asian Americans, Native Hawaiians, and Pacific Islanders are diverse in terms of occupation, experiences, visibility, and identities across Hawaiʻi, the continental U.S. and the US Associated Pacific Islands. Strategies to improve behavioral health in one region may not apply in other regions because of differences in ethnic and cultural demographics, and behavioral health care resources.Are you interested in serving on the Regional Steering Committee which will be meeting every other month? (Beginning mid-June) Which Region?(Required) Yes No Maybe - I would like more information Which Region would you represent?(Required) Region 1 - POL - AK, HI Region 2 - POL - USAPI - Federated States of Micronesia, Republic of the Marshall Islands, Republic of Palau, Guam, American Samoa, Commonwealth of the Northern Mariana Islands Region 3 - WA, OR, CA, NV, UT, AZ, NM Region 4 - ID, MT, WY, CO, ND, SD, NE, KS, OK Region 5 - MN, IA, MO, IL, MI, OH, PA Region 6 - ME, NH, VT, NY, MA, CT, RI, NJ, DE, MD, DC Region 7 - TX, LA, AR, MS, KY, TN, AL, GA, WV, VA, NC, SC, FL, Puerto Rico, US Virgin Islands To ensure equal/equitable voices as the table for our regional steering committees. We kindly ask, that you indicate which seat are interest in:I am a community-based, behavioral health practitioner serving the following populations (select all that apply): Kānaka Maoli (Native Hawaiian) Pacific Islander Asian American I am an individual or an organization representative who serves as a formal or informal referral resource for (Ex: community-based organizations, cultural practitioners, community elders, community health workers) Kānaka Maoli (Native Hawaiian) Pacific Islander Asian American I have lived-life experiences, working through, or overcoming mental health issues and I identify as (select all that apply below) Kānaka Maoli (Native Hawaiian) Pacific Islander Asian American I have lived-life experiences, working through, or overcoming substance use (select all that apply below) Kānaka Maoli (Native Hawaiian) Pacific Islander Asian American Are you interested in serving on the National Steering Committee. This will require a once-a-month meeting (Every other month at Regional Steering Committee and National Steering Committee meetings every other month staggered).(Required) Yes No Maybe - I would like more information Are you or do you work for an organization interested in serving in any other capacity for the CoE?Would you like to provide a workshop, co-sponsor events, help recruit participants for future CoE events, serve as a facilitator in community hours, provide technical assistance and/or cultural consultation, etc.(Required) Yes No Maybe - Iʻd like more information If yes above, please describe any workshops, toolkits, or resources that you or your organization may be willing to share and have featured on the ʻOhana Center of Excellence for AANHPI Behavioral Health. Please include URL and links.Would you like to be added to our new ʻOhana Center of Excellence mailing list?(Required) Yes No Do you know of any interpreters and/or translators for ʻŌlelo Hawaiʻi or Pacific Islander languages? yes no If yes above: Please state interpreter (live, spoken, in-language interpretation) or translator (written translation), which language, and how can we contact them?Any other information you would like to share with us? What did we miss? What concerns do you have? What would you like to see more of?
