Expert T/TA Consultant Application

NHTTAC Consultant and Evaluation Package

31 - Expert TTA Consultant Application - M

Expert T/TA Consultant Application

OMB: 0970-0519

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0970-0519 can be found here:

2023-03-24 - Revision of a currently approved collection

Document [pdf]

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CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-0519
Expiration Date: 05/31/2020

Consultant Network Application
Training and Technical Assistance Expert Consultant

Thank you for your interest in applying to be a consultant with the National Human Trafficking Training
and Technical Assistance Center (NHTTAC), which is administered by ICF on behalf of the U.S.
Department of Health and Human Services, Administration for Children and Families, Office on
Trafficking in Persons (OTIP). Please complete the Consultant Network Training and Technical Assistance
Expert Application as accurately as possible, as this information will be used to match your experience
with specific requests for speakers or impact statements. This application will take you approximately 15
minutes to complete. You will then be asked to submit supporting documents via email, including your
resume, CV, publications, biographical sketch, and other sample materials such as recordings of
presentations, media interviews, PowerPoint presentations, etc. You will be able to save your progress,
exit the document, and return to it as needed.
If you need assistance completing this form, or have specific questions, please contact NHTTAC at
[email protected].

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to
enable NHTTAC to collect recipient and stakeholder feedback to improve NHTTAC’s T/TA service delivery. Public reporting burden for this
collection of information is estimated to average 0.267 hours per respondent, including the time for reviewing instructions, gathering and
maintaining the data needed, and reviewing the collection of information. This collection of information is required to retain a benefit (22
USC 7104(b) and 7105(c)(4)). 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. If you have
any comments on this collection of information, please contact the NHTTAC Evaluation Team at [email protected] or 9300 Lee
Highway, Fairfax, VA 22031.

CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-0519
Expiration Date: 05/31/2020

Before proceeding with this application:
Anyone can experience vicarious trauma, compassion fatigue, and burnout at any time, which can
disrupt their ability to work in the anti-trafficking field. As a consultant, you may experience situations
that can be triggering. Please consider your well-being before submitting the application.
If you feel you are not ready to enroll as a consultant or have questions or concerns about working as a
consultant, please contact NHTTAC prior to completing this application. NHTTAC is invested in
supporting your professional development and can provide you with alternative resources to help you
continue your work in the anti-trafficking field.
Please think carefully about your decision to enroll, and consider talking with your support system
before you make your decision. You may also consider measuring your current professional quality of
care by using the Professional Quality of Life Scale (PROQOL): http://www.proqol.org/ProQol_Test.html.



I confirm that I have considered my role as a consultant, and I feel comfortable completing this
application.
I am not interested in enrolling as a consultant at this time; however, I would like to be
contacted by a training and technical assistance specialist.

In order to be an OTIP consultant, you must be a U.S. citizen or eligible to work in the United States. If
you have any questions, please contact NHTTAC at [email protected].
Are you a U.S. citizen?
□ Yes
□ No
If NO, are you eligible to work in the United States?
Are you an employee of the federal government?

□ Yes □ No
□ Yes

□ No

CONTACT INFORMATION
This section includes your contact information and preferences.
* Denotes a required field
Prefix (Mr., Ms., First Name:*
Dr., etc.):

Last Name:*

Suffix (Jr., Sr.,
etc.)

CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-0519
Expiration Date: 05/31/2020

Title:
Organization:
Preferred Address:* (FedEx and other couriers will not deliver to a P.O. box address.)
Preferred Address 2:
City:*
Business Phone:

State/
Territory:*
Business Email:

Home Phone:

Home Email:

Zip Code:*

Cell Phone:

Fax:

Preference for phone contact:

Preference for email contact:

□ Cell

□ Home

□ Business

□ Home

Country:*

□ Business

Will you be speaking, training, or providing technical assistance independently or on behalf of your agency?
□ Individual/Independent
□ Organization/Agency (If organization, please list the Federal ID#):
If enrolled as a consultant, portions of the NHTTAC consultant information (e.g., name, contact information, areas
of expertise, and biographical sketch) may be made available to organizations requesting speakers, training, or
technical assistance.
Does NHTTAC have permission to give out your contact information and biographical sketch, if requested?*
(Note: Only your name and your preferred phone and email will be provided.)
□ Yes, please share my contact information for speaking, training, and/or technical assistance purposes.
□ No, please do not release my contact information without speaking to me first.

APPLICANT INFORMATION
This section captures professional and demographic information.
Language Proficiency
Indicate what languages other than English you can speak professionally and your level of proficiency in writing
and speaking.
PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to
enable NHTTAC to collect recipient and stakeholder feedback to improve NHTTAC’s T/TA service delivery. Public reporting burden for this
collection of information is estimated to average 0.267 hours per respondent, including the time for reviewing instructions, gathering and
maintaining the data needed, and reviewing the collection of information. This collection of information is required to retain a benefit (22
USC 7104(b) and 7105(c)(4)). 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. If you have
any comments on this collection of information, please contact the NHTTAC Evaluation Team at [email protected] or 9300 Lee
Highway, Fairfax, VA 22031.

CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-0519
Expiration Date: 05/31/2020

Writing:

□ Proficient

□ Fluent

□ Native Fluency

Speaking:
Writing:

□ Proficient
□ Proficient

□ Fluent
□ Fluent

□ Native Fluency
□ Native Fluency

Speaking:
Writing:

□ Proficient
□ Proficient

□ Fluent
□ Fluent

□ Native Fluency
□ Native Fluency

Speaking:
Writing:

□ Proficient
□ Proficient

□ Fluent
□ Fluent

□ Native Fluency
□ Native Fluency

Speaking:
□ Proficient
□ Fluent
□ Native Fluency
If applicable, please provide examples of ways in which you've applied your language(s) in a professional
capacity, such as facilitating trainings or providing written materials:

Do you know how to sign?

□ Yes

□ No

If yes, please specify the type(s) of sign language you use:

CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-0519
Expiration Date: 05/31/2020

I am currently employed as or affiliated with (check all that apply):
Type of Organization
 Anti-trafficking organization
 Business/For-profit organization
 Coalition/Multidisciplinary team/Task force
 Faith-based organization
 Federal government
 State and local government
 Tribal government
 Nonprofit/Community-based organization
 OTIP grantee

CONSULTANT NETWORK
APPLICATION






OMB Control Number: 0970-0519
Expiration Date: 05/31/2020

Union/Worker advocacy organization
Victim service provider
Survivor-led organization
Self-employed:

Are you currently a member of any professional organizations (e.g., HEAL Trafficking, Toastmasters, National
Association for Social Workers, National Survivor Network)? If yes, please specify:

Race/Ethnicity and Gender (Optional)
The list below includes federal race and ethnic classifications as defined by the U.S. Office of Management and
Budget. Your voluntary cooperation in providing this information is greatly appreciated.
Race

□ American Indian or Alaska Native. A person having origins in any of the original peoples of North and
South America (including Central America) and who maintains tribal affiliation or community attachment.
□ Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the
Indian subcontinent, including Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine
Islands, Thailand, Vietnam, etc.
□ Black or African American. A person having origins in any of the black racial groups of Africa.
□ Native Hawaii or other Pacific Islander. A person having origins in any of the original peoples of Hawaii,
Guam, Samoa, or other Pacific islands.
□ White. A person having origins in any of the original peoples of Europe, the Middle East, or North
Africa.
□ If you identify as other, please specify self-identification:

Ethnicity:
Do you identify as Hispanic or Latino (a person of Mexican, Puerto Rican, Cuban, South or Central American, or
other Spanish culture or origin, regardless of race)?
□ Yes
□ No
Do you identify as Middle Eastern or North African?
□ Yes
□ No

CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-0519
Expiration Date: 05/31/2020

Gender (you may select more than one):
□ Male

□ Female □ Transgender □ Other (Please specify):

Disability or Special Needs (Optional)
Do you have one of the following? (Check all that apply.)


Visual impairments



Physical disabilities



Hearing impairments



Mental, psychological, and/or personality disorders



Other (Please specify):

For all NHTTAC-coordinated trainings and conferences, Americans with Disabilities Act compliance is a priority.
Please let us know which of the following accommodations you will need while providing training and technical
assistance for NHTTAC. (Check all that apply.)


Personal care attendant



Wheelchair accessibility (transportation, meeting space, lodging, etc.)
Type of wheelchair:

□ Manual

□ Electric



Sign language interpreter (Specify type of sign language):



Accommodations for a service animal



Convert materials into sight-assistive technology (Specify type of technology preferred):



Other (Please explain):

Survivor of Human Trafficking (Optional)
NHTTAC may receive training or technical assistance requests to learn from human trafficking survivor leaders.
Please indicate if you identify publicly as a survivor of human trafficking and are comfortable disclosing this
information in training or technical assistance. Please note that you are not required to disclose this information
in your work as a NHTTAC consultant.
□ Yes

□ No

If YES, in order to be an OTIP consultant, there must be a minimum of 3–5 years since the trafficking victimization.

 I confirm that it has been at least 3–5 years since the trafficking victimization.

CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-0519
Expiration Date: 05/31/2020

 It has not been 3–5 years since my trafficking experience; however, I would like to be
contacted by a training and technical assistance specialist who can provide me with alternative
resources for professional development.
Comment:

EDUCATION HISTORY
This section documents your academic achievements, licenses and certifications, and formal training background.
Formal Education
Please indicate the highest level of education received.
□ High school diploma or GED
□ Associate’s degree
Concentration(s):
□ Bachelor’s degree
Concentration(s):
□ Master’s degree
Concentration(s):

□ Partial/Not complete

□ Degree pending

□ Completed/Degree received
Date received/Expected:

□ Doctor of Education (Ed.D.)
Concentration(s):
□ Doctor of Philosophy (Ph.D.)
Concentration(s):
□ Doctor of Psychology (Psy.D.)

CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-0519
Expiration Date: 05/31/2020

Concentration(s):
□ Juris Doctor degree (J.D.)
Concentration(s):
□ Doctor of Dental Surgery (D.D.S.)
□ Doctor of Dental Medicine (D.M.D.)
□ Doctor of Medicine (M.D.)
□ Doctor of Osteopathic Medicine (D.O.)
□ Nurse Practitioner (N.P.)
□ Physician Assistant (P.A.)
□ Other (Please specify):
□ None
Licenses and Certifications
Please list any active licenses or certifications received that are relevant to the work of NHTTAC (e.g., Licensed
Clinical Social Worker (L.C.S.W.), Forensic Interviewer, Registered Nurse, Sexual Assault Nurse Examiner, etc.).
Title: _

Certifying/Accrediting agency:

Year:

Title:

Certifying/Accrediting agency:

Year:

Title:

Certifying/Accrediting agency:

Year:

Title:

Certifying/Accrediting agency:

Year:

Title:

Certifying/Accrediting agency:

Year:

TECHNICAL SKILLS AND EXPERIENCE AREAS
This section gathers information about your general experience in speaking and in delivering training and technical
assistance within certain substantive and functional skill areas. For each of the following categories, please confirm
that you have 5–7 years of experience providing professional services to or within the fields below by selecting items
that align with your capabilities. Be sure that for each item selected, it is reflected in your resume, CV, or other
supplemental materials.


Speaking at conference workshops or plenary sessions.

CONSULTANT NETWORK
APPLICATION



OMB Control Number: 0970-0519
Expiration Date: 05/31/2020

Designing and delivering training is the planning, development, delivery, and evaluation of activities
designed to achieve specific learning objectives for individuals, groups, or organizations. Learning objectives
may be achieved using a variety or combination of instructional strategies, and training may include onsite
instruction, classroom training, distance learning, self-directed learning, and workshops.



Developing materials and writing specific to the broader human trafficking field.



Providing capacity building technical assistance refers to professional development skills that enhance a
service provider’s ability to support survivors or those at risk of human trafficking through targeted support
or intervention to address a developmental need, resolve a problem, or create an innovative approach to an
emerging complex issue. Technical assistance may be delivered in many different ways and to varying
extents.



Program management


Board development



Collaboration and coalition building/Coordinated community response



Cultural competency



Fiscal management/Funding strategies



Grants management



Mentorship



Program development



Program evaluation



Staff and recruiting



Strategic planning



Transition management



Trauma informed programs



Volunteer recruitment and retention



Other (Please specify):

SUBJECT MATTER EXPERTISE AREAS
Please confirm you have a minimum of 7 years of experience either working within OR providing training and
technical assistance to the professional categories listed below. Be sure each item selected is reflected in your
resume, CV, or other supplemental materials.


Behavioral health professionals (e.g., psychologists, psychiatrists, mental health/substance use counselors)
 Family therapy
 Group treatment/Support group
 Individual counseling
 Peer to peer

CONSULTANT NETWORK
APPLICATION









OMB Control Number: 0970-0519
Expiration Date: 05/31/2020

 Substance use
 Culturally specific (Please specify):
 Other (Please specify):
Child welfare
 Adoption/Postadoption services
 Child abuse and neglect prevention
 Family strengthening/Family preservation/In-home services
 Family reunification
 Investigations
 Out of home/Foster care/Kinship care
 Youth in transition/Independent living/Transition planning
Corrections-based services
Criminal justice (e.g., law enforcement, prosecutor, probation, court, forensic interviewer)
Educator (e.g., teacher, professor, school administrator)
 K-8
 High school
 University
 Alternative school for at-risk students
 Youth in custody
Health care (e.g., physician, physician assistant, nurse practitioners, dentist, nurse, pharmacist)
 Community-based or mobile clinic
 Dental assistance
 Emergency response (emergency department, first responder)
 Hospital
 Private practice
 Urgent care
Housing (e.g., case workers, shelter directors, public housing authority agencies)
 Drop-in center
 Safe house
 Transitional housing
 Long-term housing
Legal (e.g., civil and/or rights-based attorney and/or paralegal, clinic)
 Employment
 Expungement/Vacatur
 Immigration
 Housing
 Family
 Other (Please specify):
Public health (e.g., licensure board, health department staff, health care executives, community health
workers)

CONSULTANT NETWORK
APPLICATION






OMB Control Number: 0970-0519
Expiration Date: 05/31/2020

Social worker (e.g., case manager, school counselor, supervisor, administrator)
Survivor empowerment, mentoring, or peer to peer
Trauma-informed services
Other (Please specify):

Vulnerable populations refers to specific or diverse populations that you have experience and expertise working
with. This is important to note because not all populations are affected by crime the same way.
Please confirm you have a minimum of 7 years of experience providing professional services to or within the fields
listed below. Be sure each item selected is reflected in your resume, CV, or other supplemental materials.


Human trafficking


Commercial sexual exploitation of children



Sex trafficking








Adults



Minors

Labor trafficking


Adults



Minors

Other (Please specify):

Children/youth


Out of home/Foster care/Kinship care



Juvenile justice



Runaway/Homeless youth



Other (Please specify):

Gender


Male



Female



Transgender



Other (Please specify):



People with disabilities



Deaf/Hearing impaired



Elderly



Lesbian, gay, bisexual, and questioning

CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-0519
Expiration Date: 05/31/2020



Foreign nationals (migrant workers, undocumented immigrants, refugees)



People with low incomes



Racial and ethnic minorities


American Indian or Alaska Native



Asian



Black or African American



Hispanic or Latino ethnicity



Middle Eastern or North African



Native Hawaii or other Pacific Islander



History of substance use



Intimate partner violence (e.g., dating, domestic violence)



Gang-related crime



Sexual abuse/Violence



Other (Please specify):

Do you have location-specific experience?


Urban



Rural



American Indian/Alaska Native reservation



U.S. territories (Please specify):

REFERENCES
Please provide two professional references. Each reference should be able to verify your expertise and experience.
Statements made on this Consultant Network Application are subject to confirmation by NHTTAC.


List only professional contacts such as current or former employers, colleagues, or peers who are familiar with
your work.

* Denotes a required field
Reference 1*
Prefix (Mr., Ms., First Name:*
Dr.):

Last Name:*

Suffix (Jr., Sr.,
etc.)

CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-0519
Expiration Date: 05/31/2020

Title:

Relationship to You:

Preferred Address:*
City:*

State:*

Phone:

ZIP Code:*

Country:*

Email:

Duration of Relationship in Years:
Reference 2*
Prefix (Mr., Ms.,
Dr.):
Title:

First Name:*

Last Name:*

Suffix (Jr., Sr.,
etc.)

Relationship to You:

Preferred Address:*
City:*

State:*

Phone:

ZIP Code:*

Country:*

Email:

Duration of Relationship in Years:
Thank you for submitting your Training and Technical Assistance Consultant Application. Please
remember to submit the required supplemental documents, including your resume, CV, publications,
biographical sketch, and any other sample materials, such as presentation recordings, media interviews,
PowerPoint presentations, etc., to [email protected]. Your application will not be considered complete
until these materials are received. Within the next 2 weeks, you will be contacted by a training and
technical assistance specialist regarding next steps.

File Type	application/pdf
File Title	31 - Expert TTA Consultant Application - M.docx
Author	Field, Michael
File Modified	2020-03-23
File Created	2020-03-20