Texas Department of State Health Services

Application for Advisory Committee Membership

If you wish to apply to be a member of the State Child Fatality Review Team Committee, please fill out this application.The committeemeets quarterly to discuss issues related to child risks and safety; develop strategies to improve child death data collection and analysis; develop position statements specific to child safety issues; and research and develop recommendations that will make Texas safer for children.The committee statutory charges are to:

  • Develop an understanding of the causes and incidences of child death in Texas.
  • Identify procedures within agencies represented on the committee to reduce the number of preventable child deaths.
  • Promote public awareness and make recommendations to the governor and legislature for changes in law, policy and practice to reduce the number of preventable child deaths.

If a question does not apply to you, enter “N/A.”

Required: Please attach a resumé or curriculum vitae.

The committee and DSHSwill use the information you put on this application and your resumé or curriculum vitae to decide if you are eligible to serve on this committee.

Important note: Advisory committee members are not paid to attend advisory committee meetings but may be reimbursed for their travel to and from meetings.

DSHS will not consider applicationsreceived after Jan. 5, 2018.

SECTION 1 - Personal Information

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Name:

Home Address:

City: State: TXZip: Phone:

Fax:Email:

Employment Information

Business/Organization:

Address:

City:State: TXZip: Phone:

Fax:Email:

Current Position Title:

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Please checkwhere you would like to receive further communications:

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Work Email Home Email Work Address Home Address

Application

New/Initial ApplicationRenewal Application

Gender

MaleFemale

Race/Ethnicity

American Indian/Alaskan Native Asian/Pacific Islander

Black Hispanic

White Other

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SECTION 2- Experience

You are required to attach a resuméor curriculum vitae.

Do you currently serve on your local child fatality review team?

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NoYes

Team name:

Do you serve in a leadership role on the team?

NoYes

Role:

Please explain why you are interested in serving on this committee.

List your relevant personal and professional achievements, including current licensures and activities that address contributions you could make to the committee.

Have you ever been disciplined by any licensing board/professional or civic organization, including the HHSC Inspector General?

No Yes

If yes, please explain:

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SECTION 3- Membership Participation

State law requires that the State Child Fatality Review Team Committee include at least one individual to represent each of the following categories.Please check the category you would like to apply for.

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Child protective services specialist

Sudden infant death syndrome family service provider

Police chief

Child educator

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Member Participation

Every member appointed to the State Child Fatality Review Team Committeemust attend regularly and must participate in subcommittee activities.

  • Regular committee meetings are held quarterly.Members must travel to Austin for these meetings.Each meeting lasts four hours.
  • Committee members are required to participate in their local child fatality review team.
  • Please note: Travel expenses to advisory committee meetings will be reimbursed.

Do you believe you will be able to regularly participate in State Child Fatality Review Team Committee activities, if you are appointed?

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NoYes

If no, please explain:

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Miscellaneous Information

Do you have a personal or private interest in a matter pending before the Texas Department of State Health Services? ("Personal or private interest" means you have a direct monetary interest in the matter or owe your loyalty to an entity involved, but does not include the member's engagement in a profession, trade or occupation when the member's interest is the same as all others similarly engaged in the profession, trade or occupation.)

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NoYes

Have you ever been convicted of a felony or misdemeanor (excluding traffic violations)?

No Yes

If yes, please explain:

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References

Please provide the names and contact information for two people who can tell us more about your qualifications to serve on the advisory committee. References can include employers, clients, religious leaders, community leaders, advocates, friends or others who know about your interest in or involvement with issues related to child risks and safety.

Reference #1

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Name:

Address:

City: State: Zip:

Daytime Phone:

Email:

Relationship (how this person knows you):

Reference #2

Name:

Address:

City: State: Zip:

Daytime Phone:

Email:

Relationship (how this person knows you):

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I confirm all the information contained in this application is true and correct.I understand that the advisory committee will meet inAustin at least four times per year.If selected, I will make every effort to attend all advisory committee meetings.

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Signature (typed name is acceptable)Date

Please return this form and any supporting documentation to:

Attn:Amy Bailey

If you have any questions about the application or the State Child Fatality Review Team Committee, please contact Amy Bailey at 512-776-2311 or by email at .

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