Division Of Addiction Services

New Jersey Department of Human Services Division of Addiction Services Prevention Strategic Planning Committee Membership Application

Purpose: The Division of Addiction Services (DAS) is soliciting applications for individuals who are interested in serving on the Prevention Strategic Planning Committee from October 2010 through March 2012. The purpose of the planning committee is to participate in the development a data-driven, five year Addiction Prevention Strategic Plan. This Plan will become a roadmap for statewide prevention activities and funding decisions. Members of the committee will be selected based upon their individual experience and knowledge of substance abuse prevention. The committee will be constituted so as to represent stakeholder groups and communities that will be a partner or participant in the Division’s substance abuse prevention programming and related activities. The Addiction Prevention Strategic Plan is intended to support population-level change across the life span, prevent misuse of substances, and reduce the harmful consequences of alcohol and drug use.

Individuals who may apply: Any individual who reflects leadership, expertise, service and or advocacy pertinent to the prevention of and/or early intervention in substance use disorders is eligible to apply, which includes the following: o Community-based prevention providers; o Persons in recovery; o Those involved in prevention/early intervention/treatment/recovery services for substance use disorders, particularly working with youth, older adults, minorities, women, disabled, and other at-risk populations; o Knowledgeable professionals such as educators, researchers, healthcare professionals, student assistance counselors, etc.; o Knowledgeable persons who have shown an interest and active involvement in the field of substance use disorders and addictions, including consumer advocates; o Officials from law enforcement, county and local government, social services, youth services, mental health or co-occurring disorders services and other such areas impacted by substance use disorders; and o Representatives of the community including individuals with expertise in the social, criminal, medical and other effects of substance abuse disorders.

The purpose of the strategic planning committee is to convene stakeholders with diverse perspectives to collaborate in the strategic planning process. The committee will include up to 15 public members selected through this application process as well as appointed members of DAS and Departmental partners. Members must volunteer to commit to at least 5 hours a month until March 15, 2011. There may be retreats and intense sessions that will require outside reading and updating of colleagues and peers. This committee is chaired by the Director of DAS.

The following skills are necessary to serve on the Strategic Planning Committee: o A collaborative spirit o Ability to be objective o Macro-level, visionary thinking o Flexibility for meetings o A “can do” attitude o Ability to meet deadlines o Experience in substance abuse prevention o An understanding of the public health model of health promotion and disease prevention o Experience in organizational planning

Location and meeting accommodations: Meetings will be held monthly at DAS’ offices in Trenton. Committee members must be available to attend the first meeting on Wednesday, October 27th from 10:00 – 1:00.

Procedure to apply: Eligible and interested individuals may obtain an application from the Department of Human Services website at http://www.state.nj.us/humanservices/providers/grants/public/. Interested individuals may also contact: Helen Staton Division of Addiction Services New Jersey Department of Human Services PO Box 362 Trenton, NJ 08625-0362 609-292-5760 [email protected]

Applications must be submitted to: One original signed application and 4 copies must be submitted to: Helen Staton Division of Addiction Services New Jersey Department of Human Services P.O. Box 362 Trenton, NJ 08625

For UPS, Fed Ex or hand delivery, please address to: Helen Staton Division of Addiction Services New Jersey Department of Human Services 120 South Stockton Street, 3rd floor Trenton, NJ 08611

Faxed or emailed applications will not be accepted. You will NOT be notified that your package has been received. If you require a phone number for delivery, you may use (609) 633-8781.

Deadline by which all applications must be submitted: Applications (including resumes) must be submitted to and received at DAS by 5:00 P.M. on Monday, October 18, 2010.

Date by which applicants will be notified: Applicants will be notified on or before October 22, 2010. Prevention Strategic Planning Committee Membership Application

Division of Addiction Services New Jersey Department of Human Services

Please complete and return to Helen Staton by October 18, 2010. Please include a copy of your resume. Attach additional sheets as needed.

Home Address:

Daytime Telephone Number:

Name and Address of Employer:

List all professional licenses and certifications:

Provide a description of your experience related to the prevention and/or treatment of substance use disorders and addictions.

What is your vision of an ideal statewide system of substance abuse prevention and early intervention services and programs?

Describe how your experience and qualifications in addictions prevention and/or early intervention is demonstrated in one or more of the following areas: Increasing access to prevention, treatment and recovery support services; improving quality of care; advocacy; research and evaluation; business or industry; primary or secondary education; post-secondary education; services to underserved populations; healthcare; mental health; community planning; faith-based services; services to youth, services to families, services to older adults; law enforcement; evidence-based prevention curricula; environmental strategies, epidemiology; and cultural competence.

What do you consider to be your principle area of expertise?

Describe what you can contribute to the prevention strategic planning committee and process?

Region of Residence: North Central South

1. Have you ever been disciplined or denied a professional license or certificate of any kind in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No 2. Have you ever had a professional license or certificate of any type suspended, revoked or surrendered in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No

3. Has any action (including the assessment of fines or other penalties) ever been taken against your professional practice by any agency or certification board in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No

4. Have you ever been named as a defendant in any litigation related to the practice of alcohol and drug counseling or other professional practice in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No

5. Are you aware of any investigation pending against a professional license or certificate issued to you by a professional board in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No

6. Are there any criminal charges now pending against you in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No

7. Have you ever been sanctioned by or is any action pending before any employer, association, society, or other professional group related to the practice of alcohol and drug counseling or other professional practice in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No

If the answer to any of the above questions, numbers 1 through 7, is “Yes,” provide a complete explanation of the circumstances leading to the action, and any supporting documentation, on separate sheets of paper.

I hereby swear that the information provided above is true to the best of my knowledge.

______Applicant Signature Date

------OPTIONAL ------Gender: Male Female

Race / Ethnicity: (Check all that apply) Asian African American Caucasian Hispanic Native American Other