No Yes If yes, please explain: What do you want to achieve through participation on this workgroup that will improve mental health access for first responders? SECTION 4 – Miscellaneous Information Have you ever had a complaint against you substantiated by any licensing board/professional or civic organization, including the HHSC Inspector General? No Yes If yes, please explain: Do you have a personal or private interest in a matter pending before the Health and Human Services Commission? ("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.) No Yes If yes, please explain: Have you ever been convicted of a felony or misdemeanor (excluding traffic violations)? No Yes If yes, please explain: 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 and/or involvement with mental health access for first responders.
No Yes If yes, please explain: What do you want to achieve through participation on this workgroup that will improve mental health access for first responders? SECTION 4 – Miscellaneous Information Have you ever had a complaint against you substantiated by any licensing board/professional or civic organization, including the HHSC Inspector General? No Yes If yes, please explain: Do you have a personal or private interest in a matter pending before the Health and Human Services Commission? ("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.) No Yes If yes, please explain: Have you ever been convicted of a felony or misdemeanor (excluding traffic violations)? No Yes If yes, please explain: 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 and/or involvement with mental health access for first responders.
hb1794-advisory-committee-application.docx