TB ETN Membership Application – 2021 1

TB Education and Training Network (TB ETN) Date: ____________________

Individual Membership Application

www.cdc.gov/tb/tbetn

Contact Information (Please print or type)

Name:

Degree(s):

Job Title:

Employer:

Mailing Address: Street ___________________________________________________________________________________

City _____________________________ State/Province ________________________________________

Zip/Postal _______________________ Country _______________________________________________

Phone: _______ Fax:

E-mail:

Type of Employer

(Check only one box)

❑ Federal government

❑ State government

❑ County/city government

❑ Non-profit agency

❑ Hospital/Acute care facility

❑ Migrant clinic

❑ Private medical office/clinic

❑ Correctional center/jails

 ___ State ___ County/City ___ Federal

❑ Homeless shelter

❑ Long-term care facility

❑ Occupational health facility

❑ University/college

❑ Community Based Organization

❑ Other (Please specify):

Type of Membership 

(Check only one box) 

OPTION 1

❑ Active 

Individuals who have the lead role for TB education and 

training in their agencies. Active members have the 

opportunity to participate in all TB ETN activities, receive 

priority registration for all TB ETN meetings and activities, 

may vote on TB ETN business-related issues, and may 

serve on workgroups.

OPTION 2

❑ Information only 

Individuals who do not have a lead role in TB education 

and training in their agencies or do not wish to actively 

participate in TB ETN activities. Information-only 

members receive information about TB ETN meetings, 

activities, etc., via e-mail postings to the membership. 

Information-only members are not eligible to vote on TB 

ETN business-related issues or serve on workgroups.

Optional — Join a Workgroup

Workgroup membership is open to all Active Members who are willing to participate in at least six (6) monthly 

conference calls and assist with workgroups activities and projects. Workgroup activities include telephone 

conference calls, development of tools to benefit TB educators, marketing of TB ETN, and planning the biennial 

conference. 

❑ Conference Planning Workgroup

I am a 

❑ New Member

❑ Renewing Member
TB ETN Membership Application – 2021 2

Additional Information

In a 40-hour work week, what percent of your time is spent on TB education and training activities? _________

In your program area, with what other TB control agencies, if any, do you collaborate? (Please list)

1.

2.

3.

Please describe your top five job responsibilities as they relate to TB education and training activities.

1. 4.

2. 5.

3.

What top five special interest/expertise areas do you have that might strengthen TB ETN?

1.

2.

3.

4.

5.

What do you hope to gain by membership in the TB ETN?

“Bringing together TB education and training professionals”

Information for New and Existing Members

Benefits of Membership

• Networking and collaborating with other TB education and training professionals

• Exchanging ideas, information, and experiences

• Accessing and sharing resources

• Collaborating on training and education research

• Receiving updated information about TB courses and training initiatives

• Building TB education and training-related skills

• Pilot testing and previewing new communication and education materials

Membership is open to all persons who have an interest in TB education and training. To activate membership, 

an individual must complete this application. New members may join TB ETN at any time during the year. There 

are no membership fees. 

If you have any questions, please contact TB ETN at tbetn@cdc.gov

Send completed membership application to:

E-mail: tbetn@cdc.gov