Demonstration Grants to Strengthen the Response to Victims of Human Trafficking in Native Communities (VHT-NC) Program Evaluation – Community Expert Consultant Recruitment

OMB Control Number: 0970-0477

Expiration Date: 04/30/2022

Demonstration Grants to Strengthen the Response to Victims of Human Trafficking in Native Communities (VHT-NC) Program Evaluation – Community Expert Group (CEG): Nomination Form 

Your responses to this form:

• Are voluntary

• Will be used to help the evaluation team select expert consultants for the Community Expert Group

• Will be securely stored and not accessible to anyone outside of the evaluation team

• Will be maintained through the duration of the evaluation and then will be destroyed

Are you 18 years or older? Yes | No

[If NO, exit form]

What is your first and last name? _______________________ 

 What is your gender? _____________ 

What is your tribal heritage or affiliation? _______________________ 

• N/A: I do not identify as Native Hawaiian/Pacific Islander, American Indian, Alaskan Native, or indigenous 

What is your experience or expertise related to human trafficking? (e.g., direct services with people impacted by human trafficking, victim advocate, public defender, nurse, law enforcement officer, social worker, lived experience, etc.). Please describe.

____________________________________________________________________________________

Are you familiar with the work of one of the VHT-NC Program grant recipients? If so, please describe: _________

Why do you want to participate in the CEG? __________________________ 

What knowledge, perspective, or strengths would you bring to the CEG? __________________

Do you feel that you have the supports necessary (emotional, spiritual, physical) to participate in a group that discusses human trafficking over the next three years? _________________________ 

A good phone number to reach you at: _________________________ (Can we text you: Y/N) 

Email address: ____________________________ 

How would you like the evaluation team to reach out to you? (Select all that apply)

• Telephone call

• Text message

• Email

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to select qualified community expert consultants. Public reporting burden for this collection of information is estimated to average 20 minutes per respondent, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB number is 0970-0477 and the expiration date is 04/30/2022.