Form 1 Mandatory Individuals

CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-XXXX
Expiration Date: XX/XX/XXXX

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
svega@nhttac.org.

Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid
OMB control number. The estimated average time to complete this form is 15 minutes. If you have comments regarding the
accuracy of this estimate or additional suggestions, please write to the NHTTAC Evaluation Team at NHTTACEval@icf.com or
9300 Lee Highway, Fairfax, VA 22031.

1

CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-XXXX
Expiration Date: XX/XX/XXXX

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 info@nhttac.org.
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.)
2

Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid
OMB control number. The estimated average time to complete this form is 15 minutes. If you have comments regarding the
accuracy of this estimate or additional suggestions, please write to the NHTTAC Evaluation Team at NHTTACEval@icf.com or
9300 Lee Highway, Fairfax, VA 22031.

CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-XXXX
Expiration Date: XX/XX/XXXX

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.
3
Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid
OMB control number. The estimated average time to complete this form is 15 minutes. If you have comments regarding the
accuracy of this estimate or additional suggestions, please write to the NHTTAC Evaluation Team at NHTTACEval@icf.com or
9300 Lee Highway, Fairfax, VA 22031.

CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-XXXX
Expiration Date: XX/XX/XXXX

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:
_________________________________________________
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
4
Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid
OMB control number. The estimated average time to complete this form is 15 minutes. If you have comments regarding the
accuracy of this estimate or additional suggestions, please write to the NHTTAC Evaluation Team at NHTTACEval@icf.com or
9300 Lee Highway, Fairfax, VA 22031.

CONSULTANT NETWORK
APPLICATION






OMB Control Number: 0970-XXXX
Expiration Date: XX/XX/XXXX

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

5
Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid
OMB control number. The estimated average time to complete this form is 15 minutes. If you have comments regarding the
accuracy of this estimate or additional suggestions, please write to the NHTTAC Evaluation Team at NHTTACEval@icf.com or
9300 Lee Highway, Fairfax, VA 22031.

CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-XXXX
Expiration Date: XX/XX/XXXX

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.

6
Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid
OMB control number. The estimated average time to complete this form is 15 minutes. If you have comments regarding the
accuracy of this estimate or additional suggestions, please write to the NHTTAC Evaluation Team at NHTTACEval@icf.com or
9300 Lee Highway, Fairfax, VA 22031.

CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-XXXX
Expiration Date: XX/XX/XXXX

 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.)

7
Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid
OMB control number. The estimated average time to complete this form is 15 minutes. If you have comments regarding the
accuracy of this estimate or additional suggestions, please write to the NHTTAC Evaluation Team at NHTTACEval@icf.com or
9300 Lee Highway, Fairfax, VA 22031.

CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-XXXX
Expiration Date: XX/XX/XXXX

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.
8
Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid
OMB control number. The estimated average time to complete this form is 15 minutes. If you have comments regarding the
accuracy of this estimate or additional suggestions, please write to the NHTTAC Evaluation Team at NHTTACEval@icf.com or
9300 Lee Highway, Fairfax, VA 22031.

CONSULTANT NETWORK
APPLICATION



OMB Control Number: 0970-XXXX
Expiration Date: XX/XX/XXXX

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
9
Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid
OMB control number. The estimated average time to complete this form is 15 minutes. If you have comments regarding the
accuracy of this estimate or additional suggestions, please write to the NHTTAC Evaluation Team at NHTTACEval@icf.com or
9300 Lee Highway, Fairfax, VA 22031.

CONSULTANT NETWORK
APPLICATION















OMB Control Number: 0970-XXXX
Expiration Date: XX/XX/XXXX

 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)
10
Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid
OMB control number. The estimated average time to complete this form is 15 minutes. If you have comments regarding the
accuracy of this estimate or additional suggestions, please write to the NHTTAC Evaluation Team at NHTTACEval@icf.com or
9300 Lee Highway, Fairfax, VA 22031.

CONSULTANT NETWORK
APPLICATION






OMB Control Number: 0970-XXXX
Expiration Date: XX/XX/XXXX

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
11
Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid
OMB control number. The estimated average time to complete this form is 15 minutes. If you have comments regarding the
accuracy of this estimate or additional suggestions, please write to the NHTTAC Evaluation Team at NHTTACEval@icf.com or
9300 Lee Highway, Fairfax, VA 22031.

CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-XXXX
Expiration Date: XX/XX/XXXX



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.)
12

Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid
OMB control number. The estimated average time to complete this form is 15 minutes. If you have comments regarding the
accuracy of this estimate or additional suggestions, please write to the NHTTAC Evaluation Team at NHTTACEval@icf.com or
9300 Lee Highway, Fairfax, VA 22031.

CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-XXXX
Expiration Date: XX/XX/XXXX

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 svega@nhttac.org. 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.

13
Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid
OMB control number. The estimated average time to complete this form is 15 minutes. If you have comments regarding the
accuracy of this estimate or additional suggestions, please write to the NHTTAC Evaluation Team at NHTTACEval@icf.com or
9300 Lee Highway, Fairfax, VA 22031.

OMB Control Number: 0970-XXXX
Expiration date: XX/XX/XXXX

National Human Trafficking Training and Technical Assistance Center
Professional Development Scholarship Application
Thank you for your interest in the Professional Development Scholarship Program. This
application will allow us to learn more about you, your organization, and the event you are
planning to attend. NHTTAC offers the professional development scholarships to individuals
and multidisciplinary teams (MDT) that work with human trafficking survivors and/or
populations at risk of human trafficking. Scholarships are awarded to enhance the
recipient’s ability to deliver a public health response to human trafficking.
The National Human Trafficking Training and Technical Assistance Center (NHTTAC) must
receive the completed Individual or Multidisciplinary Team (MDT) Professional
Development Scholarship application at least 60 calendar days prior to the event or the
request will be rejected - NO EXCEPTIONS. Please note: All MDT members must complete
their own applications and must all be submitted within 48 hours of each other.
For assistance, please contact NHTTAC by calling toll free (844) 648-8822 or emailing
info@nhttac.org

Section A: Applicant Information
This section will provide additional information about you, the applicant.

1. Name of Applicant:
2. Home Address:
3. City
4. Phone:

State:
Fax:

ZIP Code:

Email Address:

5. __Individual Application
__Multidisciplinary Team Application
o Team Name: __________________________
o Team Coordinator: _____________________
o Number of Team Members: _______
o Names of Team Members:
 _______________________________
 _______________________________
 _______________________________
 _______________________________
 _______________________________

1

NHTTAC Professional Development Scholarship Application (Continued)
6. How long have you worked with human trafficking survivors and/or populations at risk of
human trafficking? Please specify length of time.
 1-3 years
 3-5 years
 More than 5 years

7. Please provide a detailed description of the direct services you currently provide to
victims of human trafficking and/or populations at risk of human trafficking. (Minimum
of five sentences)

8. Please provide a detailed explanation of how you will use the information you learn to
improve your work with human trafficking and/or populations at risk of human
trafficking. Please provide examples where appropriate. (Minimum of five sentences)

Section B: Organization Information
This section will provide additional information about your organization.

7. Name of Organization:
8. Name and Title of Organization’s Chief Executive:
9. Street Address:
10. City:

11. Phone:

State:

Zip Code:

Fax:

Website:

12. Applicant’s Position/Title:
13. Type of Organization and/or Role. Select all that apply.
Type of Organization
 Anti-trafficking organization
 Business/for-profit organization
 Coalition/Multidisciplinary Team/Task Force
 Federal government
 Faith-based organization
 State/Local Government
2

NHTTAC Professional Development Scholarship Application (Continued)






Nonprofit/community-based organization
Survivor led organization
Tribal government
Union/worker advocacy organization
Victim service provider

Professional Capacity and Types of Services
 Behavioral health professional (psychologist, psychiatrist, mental health/substance
use counselor)
 Child welfare (state agency staff; child welfare contractor; non-profit personnel)
 Corrections Based Services
 Criminal justice (e.g., law enforcement, prosecutor, probation, court)
 Educator (teacher, professor, school administrator)
 Health care (physician, physician assistant, nurse practitioner, dentist, nurse,
pharmacist)
 Housing (case worker, shelter director, public housing authority agencies)
 Legal (civil and/or rights-based attorney and/or paralegal, clinic)
 Public health (health department staff, health care executive, community health
workers)
 Social worker (case manager, school counselor, supervisor, administrator)
 Survivor Empowerment and Mentoring
 Other (Specify): __________________

14. Have you or your organization received a NHTTAC Professional Development Scholarship
from in the past 12 months?
__ Yes

__ No

Section C: Event Information
This section will provide additional information about the event you are planning to attend.

15. Event Title:
16. Date(s):
Location (City, State):
17. Name of Organization Sponsoring the Event:
18. Will you be featured as a speaker or trainer at this event? __ Yes__ No
19. Event Website (If available):

Section D: Budget Information
This section will provide information about your anticipated expenses and expenses to be covered by
your organization.

3

NHTTAC Professional Development Scholarship Application (Continued)
Applicants are eligible to receive scholarship funds up to $500 for individuals, $1,500 for
multidisciplinary teams. Allowable expenses include tuition/registration fees (late fees are
not allowable), transportation, and lodging. Applicants are eligible to receive up to $500 per
individual recipient for transportation expenses (such as airfare, train, or bus fare), and
lodging expenses (up to the federal government rate in that area, for current rates, please
visit www.gsa.gov). Rental car services are not reimbursable under any circumstances.
Lodging is not covered by the scholarship if the recipient lives within 50 miles of the event.
Expenses will be paid directly on awardees behalf by NHTTAC and our travel agency in
advance of the event. An application missing the following information will be considered
incomplete and rejected. All fields are required; where you are not requesting expense
reimbursements, please enter $0.
Please Note: Scholarship approval is not guaranteed. We advise you not to make any
financial commitment until you receive confirmation from NHTTAC.
A. Expenses

Total

Number of Event Days
Tuition/Registration Fee
No. of Days

Leave Blank

Lodging
(Lodging allowance will be calculated by NHTTAC based on per diem rates for
event location.)

Mode of
Leave Blank
Transportation
Travel (airfare/train/bus) not to exceed $500.
(Travel will be arranged through the NHTTAC travel department. Rental cars are
not allowable under any circumstances)

Please identify which mode of travel is needed for arrival and
departure, and include the dates of travel.
B. Expenses to be Covered by Your Organization

Total

What other expenses will your organization cover?
(Enter $0 if no funds are available.)

C. Division/Unit/Department’s Budget Information
(Enter $0 for any fields where no funds are available.)

What is your division/unit/department’s current total operating budget?
If $0, please explain here:

4

NHTTAC Professional Development Scholarship Application (Continued)
What is your division/unit/department’s current training budget?
If $0, please explain here:

How many people does your division/unit/department employ?
Training Budget Comments:
Please use this section to explain items included within the budget figure that might decrease the amount of training
funds allotted to you. Example: if your division/unit/department’s training budget also includes a trainer’s salary, please
mention that here and the amount of the salary.

Section E: Scholarship Concurrence
This ensures that the information provided in Sections A to D, to the best of your knowledge, is
accurate.

I, as the scholarship applicant, certify that:
(1) The information provided in this application is accurate;
(2) I have at least 1 year of experience serving human trafficking survivors and/or
populations at risk of human trafficking;
(3) My organization supports the event and scholarship request, but is unable to
completely underwrite the professional development activity for which I am
requesting support; or I work independently and have attached a letter of support
from someone with whom I have an established working relationship; and
(4) I agree to abide by all requirements noted in this application.
I understand and agree that any false information, misrepresentation, or willful or negligent
failure to disclose any information pertinent to this application or my organization will
constitute sufficient grounds for the removal of my application from consideration, the
return of funding by my organization to the National Human Trafficking Training and
Technical Assistance Center if funding has been granted, and/or disqualification of my
organization from future scholarship opportunities.
______________________________
Signature of Applicant

______________________________
Date

Section F: Supervisor/Chief Executive Attestation
This section ensures that your supervisor or organization’s chief executive supports your attendance at
the training event and all requirements associated with receiving the scholarship. Please note: If you
work independently, you must instead attach a letter of support from someone with whom you have
working relationship.

5

NHTTAC Professional Development Scholarship Application (Continued)
I support my employee’s Professional Development Scholarship application. I acknowledge
that should a scholarship be awarded, the employee will be permitted to attend the event
and will be supported in the fulfillment of all scholarship requirements. NHTTAC is welcome
to contact me directly to obtain feedback on the impact of the training on my employee’s
ability to provide quality victim services.
_______________________________________________ ______________________
Signature of Supervisor
Date
________________________________________________________________________
Printed Name of Supervisor
________________________________________________________________________
Title of Supervisor
________________________________________________________________________
Name of Organization
______________________________
Phone Number

______________________________
E-mail Address

Please email the completed application to info@nhttac.org with the subject line stating,
“Professional Development Scholarship Application.”

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)
Public reporting burden of this collection of information is estimated to average 20 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information. An agency may not conduct or
sponsor, and a person is not required to respond to a collection of information unless it displays a currently
valid OMB control number.
Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden to DHHS/ACF Reports Clearance Officer; 370 L’Enfant Promenade, S.W.;
Washington, D.C. 20447

6

CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-XXXX
Expiration Date: XX/XX/XXXX

Consultant Network Application
Survivor 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
svega@nhttac.org.

Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid
OMB control number. The estimated average time to complete this form is 15 minutes. If you have comments regarding the
accuracy of this estimate or additional suggestions, please write to the NHTTAC Evaluation Team at NHTTACEval@icf.com or
9300 Lee Highway, Fairfax, VA 22031.

1

CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-XXXX
Expiration Date: XX/XX/XXXX

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 an application.
If you feel that 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, 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.
 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.
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 info@nhttac.org.
Are you a U.S. citizen?
□ Yes
□ No
If NO, are you eligible to work in the United States?

□ Yes □ No

Are you an employee of the federal government?

□ Yes

□ No

Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid
OMB control number. The estimated average time to complete this form is 15 minutes. If you have comments regarding the
accuracy of this estimate or additional suggestions, please write to the NHTTAC Evaluation Team at NHTTACEval@icf.com or
9300 Lee Highway, Fairfax, VA 22031.

2

CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-XXXX
Expiration Date: XX/XX/XXXX

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

Last Name:*

Suffix (Jr., Sr.,
etc.)

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 Tax 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 survivor impact
speakers. 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 speaker requests.
□ No, please do not release my contact information without speaking to me first.

Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid
OMB control number. The estimated average time to complete this form is 15 minutes. If you have comments regarding the
accuracy of this estimate or additional suggestions, please write to the NHTTAC Evaluation Team at NHTTACEval@icf.com or
9300 Lee Highway, Fairfax, VA 22031.

3

CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-XXXX
Expiration Date: XX/XX/XXXX

APPLICANT INFORMATION
This section captures professional and demographic information.
Language Proficiency
Indicate what languages other than English you can speak in a professional capacity and your level of proficiency in
writing and speaking.
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:

Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid
OMB control number. The estimated average time to complete this form is 15 minutes. If you have comments regarding the
accuracy of this estimate or additional suggestions, please write to the NHTTAC Evaluation Team at NHTTACEval@icf.com or
9300 Lee Highway, Fairfax, VA 22031.

4

CONSULTANT NETWORK
APPLICATION

Do you know how to sign?

□ Yes

OMB Control Number: 0970-XXXX
Expiration Date: XX/XX/XXXX

□ No

If yes, please specify the type(s) of sign language you use:
_________________________________________________
Employment
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
 Union/Worker advocacy organization
 Victim service provider
 Survivor-led organization
 Self-employed:_________
 Other:_____________
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.
Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid
OMB control number. The estimated average time to complete this form is 15 minutes. If you have comments regarding the
accuracy of this estimate or additional suggestions, please write to the NHTTAC Evaluation Team at NHTTACEval@icf.com or
9300 Lee Highway, Fairfax, VA 22031.

5

CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-XXXX
Expiration Date: XX/XX/XXXX

□ 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
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 (Specify): _________
Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid
OMB control number. The estimated average time to complete this form is 15 minutes. If you have comments regarding the
accuracy of this estimate or additional suggestions, please write to the NHTTAC Evaluation Team at NHTTACEval@icf.com or
9300 Lee Highway, Fairfax, VA 22031.

6

CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-XXXX
Expiration Date: XX/XX/XXXX

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

□ Partial/Not complete

□ Degree pending

□ Completed/Degree received
Date received/Expected: ______________

Concentration(s):
_____________________________________
□ Doctor of Psychology (Psy.D.)
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.)

Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid
OMB control number. The estimated average time to complete this form is 15 minutes. If you have comments regarding the
accuracy of this estimate or additional suggestions, please write to the NHTTAC Evaluation Team at NHTTACEval@icf.com or
9300 Lee Highway, Fairfax, VA 22031.

7

CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-XXXX
Expiration Date: XX/XX/XXXX

□ Doctor of Osteopathic Medicine (D.O.)
□ Nurse Practitioner (N.P.)
□ Physician Assistance (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: ______

SURVIVOR EXPERIENCE
As a consultant, NHTTAC may receive requests for training or technical assistance specific to learning from survivors’
experiences. This section gathers information about your personal experience and your experience delivering a
message to inform the identification of and/or service delivery to human trafficking survivors.
PLEASE NOTE: The information you provide will give NHTTAC a clear understanding of your experiences, helping to
match you to incoming requests for assistance. This information is never disseminated and remains protected
within NHTTAC as part of your application. This portion of the application is optional. If you have questions or
concerns, please contact NHTTAC at info@nhttac.org.
Please select specific or diverse populations that reflect your past and inform your current work. (Check all that
apply.)


Human trafficking


Commercial sexual exploitation of children



Sex trafficking





Adults



Minors

Labor trafficking

Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid
OMB control number. The estimated average time to complete this form is 15 minutes. If you have comments regarding the
accuracy of this estimate or additional suggestions, please write to the NHTTAC Evaluation Team at NHTTACEval@icf.com or
9300 Lee Highway, Fairfax, VA 22031.

8

CONSULTANT NETWORK
APPLICATION








Adults



Minors

OMB Control Number: 0970-XXXX
Expiration Date: XX/XX/XXXX

Other (Please specify): __________________

Children/youth


Out of home/Foster care/Kinship care



Runaway/Homeless youth



Juvenile justice



Other (Please specify): __________________

Gender


Male



Female



Transgender



Other (Please specify): __________________



People with disabilities



Deaf/Hearing impaired



Elderly



History of prior victimization



Lesbian, gay, bisexual, and questioning individuals



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
Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid
OMB control number. The estimated average time to complete this form is 15 minutes. If you have comments regarding the
accuracy of this estimate or additional suggestions, please write to the NHTTAC Evaluation Team at NHTTACEval@icf.com or
9300 Lee Highway, Fairfax, VA 22031.

9

CONSULTANT NETWORK
APPLICATION



OMB Control Number: 0970-XXXX
Expiration Date: XX/XX/XXXX

Other (Please specify): __________________

Do you have location-specific experience?


Urban



Rural



American Indian/Alaska Native reservation



U.S. territories (Please specify): __________________

Type of crime you survived (check all that apply):
 Labor trafficking as an adult
 Labor trafficking as a minor (age 17 or younger)
 Sex trafficking as an adult
 Sex trafficking as a minor (age 17 or younger)


Other (Please specify): ________________________________________

PROFESSIONAL EXPERIENCE
For each of the following categories, please confirm you have 2–3 years of consistent experience integrating your
personal experience in delivering a message to inform the identification of and/or service delivery to human
trafficking survivors or those at risk of human trafficking. Be sure each item selected is reflected in your resume, CV,
or other supplemental materials.


Participation in strategizing coordinated community response and outreach planning



Provision of personal impact statements or as an expert witness (including testimony in legislative, civil, or
criminal hearings)



Review of documents (e.g., reports, program fact sheets) or products (e.g., outreach materials, DVDs)



Delivery of remarks to community/civic organizations, social service providers, educators, or public health
organizations



Public speaking at conferences or other human trafficking awareness events



Delivery of messages to the media (including print, online, or broadcast)



Other (Please specify): ________________________________________

Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid
OMB control number. The estimated average time to complete this form is 15 minutes. If you have comments regarding the
accuracy of this estimate or additional suggestions, please write to the NHTTAC Evaluation Team at NHTTACEval@icf.com or
9300 Lee Highway, Fairfax, VA 22031.

10

CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-XXXX
Expiration Date: XX/XX/XXXX

This next section is about identifying your target audience. NHTTAC would like to support you in delivering your
message to audiences that you prefer to work with. For each of the fields listed, please select and mark the column
that best describes your current interest in delivering your message to them. Please note: NHTTAC understands that
your answers to these questions may change as you continue to work in the trafficking field. You will have the
opportunity to update your answers at a later time.
Target Audience

2-3 years
of
experienc
e in
providing
training
to this
field

I would
like to
consult
with this
field.

I do not
currently
wish to
consult
with this
field.

Unsure

Comments:

Anti-trafficking
organizations
Behavioral health
professionals (e.g.,
psychologists,
psychiatrists, mental
health/substance use
counselors)
Business/For-profit
organizations
Child welfare
Coalitions/Multidisciplin
ary teams/Task forces
Corrections-based
services
Criminal justice (e.g.,
law enforcement,
prosecutor, probation,
court, forensic
interviewer)

Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid
OMB control number. The estimated average time to complete this form is 15 minutes. If you have comments regarding the
accuracy of this estimate or additional suggestions, please write to the NHTTAC Evaluation Team at NHTTACEval@icf.com or
9300 Lee Highway, Fairfax, VA 22031.

11

CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-XXXX
Expiration Date: XX/XX/XXXX

Educators (e.g.,
teachers, professors,
school administrators)
Faith-based
organizations
Federal government
Health care (e.g.,
physician, physician's
assistant, nurse
practitioner, dentist,
nurse, pharmacist)
Housing (e.g., case
workers, shelter
directors, public housing
authority agencies)
Legal (e.g., civil and/or
rights-based attorney
and/or paralegal, clinic)
Nonprofit/Communitybased organizations
Public health (e.g.,
health department staff,
health care executives,
community health
workers)
Social workers (e.g.,
case managers, school
counselors, supervisors,
administrators)
State and local
government
Survivor empowerment,
mentoring, or peer to
peer programming
Survivor-led
organizations

Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid
OMB control number. The estimated average time to complete this form is 15 minutes. If you have comments regarding the
accuracy of this estimate or additional suggestions, please write to the NHTTAC Evaluation Team at NHTTACEval@icf.com or
9300 Lee Highway, Fairfax, VA 22031.

12

CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-XXXX
Expiration Date: XX/XX/XXXX

Trauma informed
programming
Tribal government
Union/Worker advocacy
organizations
Victim service providers
Other (Please specify):
__________________

CONSULTATION INFORMATION
Please describe your area of focus and expertise in the field below. Be sure to include the following information in
your description:


What is the focus of your work in the anti-trafficking field (e.g., prevention, LGBTQ, domestic minor sex
trafficking)?



What do you want recipients to know about human trafficking, the reporting process, the healing process, etc.?
What do you want to see change?

Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid
OMB control number. The estimated average time to complete this form is 15 minutes. If you have comments regarding the
accuracy of this estimate or additional suggestions, please write to the NHTTAC Evaluation Team at NHTTACEval@icf.com or
9300 Lee Highway, Fairfax, VA 22031.

13

CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-XXXX
Expiration Date: XX/XX/XXXX

REFERENCES
Please provide two references. Each reference should be able to describe your experience working in the antitrafficking field. Statements made on this Consultant Network Application are subject to confirmation by NHTTAC.


List only professional contacts such as current or former employers, colleagues, peers, or others who are familiar
with your presentations on crime victimization.



List at least two references who can provide a thorough summary of your ability to speak about your personal
victimization experience to varied public audiences.

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

Last Name:*

Suffix (Jr., Sr.,
etc.)

Relationship to You:

Preferred Address:*
City:*

State:*

Zip Code:*

Country:*

Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid
OMB control number. The estimated average time to complete this form is 15 minutes. If you have comments regarding the
accuracy of this estimate or additional suggestions, please write to the NHTTAC Evaluation Team at NHTTACEval@icf.com or
9300 Lee Highway, Fairfax, VA 22031.

14

CONSULTANT NETWORK
APPLICATION

Phone:*

OMB Control Number: 0970-XXXX
Expiration Date: XX/XX/XXXX

Email:*

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

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 svega@nhttac.org. 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.

Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid
OMB control number. The estimated average time to complete this form is 15 minutes. If you have comments regarding the
accuracy of this estimate or additional suggestions, please write to the NHTTAC Evaluation Team at NHTTACEval@icf.com or
9300 Lee Highway, Fairfax, VA 22031.

15