Advisory Committee Application

Department of State Health Services General Academic Teaching Institution Application (4 year institution)

If you wish to be a member of the Stock Epinephrine Advisory Committee, please fill out this application. The committee examines and reviews the administration of epinephrine auto-injectors to a person experiencing an anaphylactic reaction on a campus of a school district, an open-enrollment charter school, private school, or an institution of higher education. The committee shall advise the Department of State Health Services commissioner on:

1. The storage and maintenance of epinephrine auto-injectors on school campuses and campuses of institutions of higher learning. 2. The training of school personnel and school volunteers, and of personnel and volunteers at institutions of higher learning, in the administration of an epinephrine auto-injector. 3. A plan for: A. One or more school personnel members or school volunteers trained in the administration of an epinephrine auto-injector to be on each campus. B. One or more personnel members or volunteers of an institution of higher education trained in the administration of an epinephrine auto- injector to be on each campus of an institution of higher education.

DSHS will use the information you put on this application to decide if you are eligible to serve on this committee.

Important note: Committee members serve without compensation but are reimbursed for their travel to and from meetings.

DSHS will not consider an application received or postmarked after Nov. 30, 2017.

SECTION 1 - Personal Information Name: Home Address: City: State: TX Zip: County: Phone: Fax: Email:

P.O. Box 149347 ∙ Austin, Texas 71714-9347 ∙ Phone: 888-963-7111 ∙ TTY: 800-735-2889 ∙ www.dshs.texas.gov Employment Information Name of Public Junior College/Technical Institute: Address: City: State: TX Zip: County: Phone: Fax: Email: Current Position Title:

Please check where you would like to receive further communications: Work Email Home Email Work Address Home Address

Application New/Initial Application Renewal Application Gender Male Female Race/Ethnicity American Indian/Alaskan Native Asian/Pacific Islander Black Hispanic White Other

SECTION 2 (Employee from General Academic Teaching Institution - Applicants Only) An employee from a general academic teaching institution, as defined in Education Code, Section 61.003, may apply to be on this committee. Please complete SECTION 2 only if you are an employee from a general academic teaching institution.

1. Please tell us about your direct knowledge and experience with risk management, administrative regulations development, and policy development related to student health and safety within a public junior college or public technical school. A minimum of 3-5 years is required.

2. Please describe your experience working with campus police and/or facilities management related to student health and safety.

2 3. Please describe your experience in student health and safety services coordination (on a campus level), or any related experience, if applicable.

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

5. Please describe your experience working with a general academic teaching institution’s health center and interacting and collaborating with personnel and campus life.

6. Please tell us why you want to serve on this committee.

Member Participation Every member appointed to the committee must attend and participate in the meetings. Once the appointment process is complete, it is anticipated that the committee will meet in Austin up to three times during the following twelve months. Appointed members of the committee serve without compensation but are entitled to reimbursement for travel expenses.

Do you believe you will be able to regularly participate in SEAC activities, if you are appointed? Yes No

If no, please explain:

Miscellaneous Information Do you have a personal or private interest in a matter pending before DSHS or 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.) Yes No

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

3 Yes No 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 service delivery.

Reference #1 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):

4 All the information contained in this application is true and correct. I understand that the committee will meet in Austin up to three times per year once the appointment process is complete. If selected, I will make every effort to attend all committee meetings.

Signature (typed name is acceptable) Date

Please return this form and any supporting documentation to:

Email: [email protected] Subject: SEAC Member Application

Mail: Texas School Health Program Texas Department of State Health Services P.O. Box 149347, Mail Code 1925 Austin, Texas 78714-9347

Fax: 512-776-7555 Attn: School Health Program – Anita Wheeler Subject: SEAC Member Application

If you have any questions about the application or the Stock Epinephrine Advisory Committee, please contact Anita Wheeler at (512) 776-2909 or by email at [email protected].