Survivor Consultant Network Application

CONSULTANT NETWORK
APPLICATION

OMB Control Number: 0970-0519
Expiration Date: 10/31/2021

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 17 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: 0970-0519
Expiration Date: 10/31/2021

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 17 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: 0970-0519
Expiration Date: 10/31/2021

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 17 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: 0970-0519
Expiration Date: 10/31/2021

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 17 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?

OMB Control Number: 0970-0519
Expiration Date: 10/31/2021

□ Yes

□ 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 17 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: 0970-0519
Expiration Date: 10/31/2021

□ 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 17 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: 0970-0519
Expiration Date: 10/31/2021

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 17 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: 0970-0519
Expiration Date: 10/31/2021

□ 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 17 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: 0970-0519
Expiration Date: 10/31/2021

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 17 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: 0970-0519
Expiration Date: 10/31/2021

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 17 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: 0970-0519
Expiration Date: 10/31/2021

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 17 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: 0970-0519
Expiration Date: 10/31/2021

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 17 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: 0970-0519
Expiration Date: 10/31/2021

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 17 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: 0970-0519
Expiration Date: 10/31/2021

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 17 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: 0970-0519
Expiration Date: 10/31/2021

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 17 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