ࡱ> kmje KdbjbjJJ =f(_b(_b'% ppppp D^4hdv=D$3333333$6|93-p3pp4 .pp3 3 O0|1ߣ?03.40^40::$11&:p1 33^4: B 6: Division of Mental Health and Addiction Services Addictions Professional Advisory Committee Call for Members and Application Purpose: The Division of Mental Health and Addiction Services (DMHAS) is soliciting applications for individuals who are interested in serving on the Addictions Professional Advisory Committee (PAC) from November 2020 through October 2022. The purpose of the PAC is to make recommendations pertinent to substance use disorders and addictions to the Commissioner of the Department of Human Services (DHS) through DMHAS. Members of the PAC are NOT selected as representatives of their respective provider agency; rather, members are chosen for their individual experience, knowledge and ability to liaison with DMHAS on substance use and/or co-occurring disorders. In order to best represent the individuals served in the fieldof Substance Use Disorder Treatment and Prevention, we will strive to ensure cultural diversity and include individuals who identify as having lived experience on the PAC. Individuals who may apply: Any individual who reflects leadership, expertise, service and or advocacy pertinent to prevention, early intervention, treatment and recovery related to substance use disorders and co-occurring disorders is eligible to apply, which includes the following: Persons with lived experience who are in recovery, or those involved in prevention/early intervention/treatment/recovery of substance use disorders, particularly youth, elderly, minority, women, disabled and other at-risk populations; Knowledgeable professionals such as educators, researchers, etc.; Knowledgeable persons who have shown an interest and active involvement in the field of substance use and/or co-occurring disorders and addictions, including consumer advocates; Officials from law enforcement, local government, social services, youth services, mental health or co-occurring disorders services and other such areas impacted by substance use disorders; Representatives of the community including individuals with expertise in the social, criminal, medical and other effects of substance abuse and/or co-occurring disorders; and Individuals with expertise in substance abuse, mental health and/or co-occurring disorders. Applicants must live and/or work in NJ. Qualifications needed by an applicant to be considered: Applicants should have demonstrated competency in one or more of the following areas: Knowledge of New Jersey behavioral health systems; Knowledge of substance use disorder prevention, early intervention, treatment and recovery support services; Knowledge of mental health services and systems; Improving quality of care; Medical linkage; Improving service efficiency; Improving outcome measurement; Increasing available resources; Workforce development; Needs assessment/data; Performance based contracting; Knowledge/experience with administrative service organizations; Integration with primary health care; Improving performance; Utilization management; Improving co-occurring substance abuse/ mental health integration; Lived experience as a person in SUD/Co-Occurring recovery or as family member of an individual in recovery. Location and meeting accommodations: Meetings will be held monthly on the third Friday from 10:00 a.m. to 12:00 p.m. at the DMHAS Main Office, located at 5 Commerce Way, Suite 100, Hamilton, New Jersey, conference room 199A. PAC meetings may also be held remotely, as needed. Procedure to apply: Eligible and interested individuals may obtain an application from the Department of Human Services website at  HYPERLINK "https://www.nj.gov/humanservices/dmhas/home/councils/pac.htm" https://www.nj.gov/humanservices/dmhas/home/councils/pac.htm Interested individuals may also contact Alicia Meyer by e-mail at  HYPERLINK "mailto:alicia.meyer@dhs.nj.gov" alicia.meyer@dhs.nj.gov Applications must be submitted to: One original signed application and 5 copies must be submitted to: Alicia Meyer Division of Mental Health and Addiction Services New Jersey Department of Human Services P.O. Box 362 Hamilton, NJ 08619 For UPS, Fed Ex or hand delivery, please alter address to read: 5 Commerce Way, Suite 100 Hamilton, NJ 08619 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) 438-4353. Deadline by which all applications must be submitted: Applications (including licenses/credentials and resumes) must be postmarked by September 30, 2020. Date by which applicants will be notified: Applicants will be notified on or before November 2, 2020. Professional Advisory Committee Application Division of Mental Health and Addiction Services New Jersey Department of Human Services Please complete and return an original and 5 copies to Alicia Meyer by September 30, 2020. Be sure to include copies of all credentials/licenses and your resume in your original application and 5 copies. Attach additional sheets as needed. Name: Home Address: Daytime Telephone Number: Cell Phone Number: Email Address: Name and Address of Employer: List all professional licenses and certifications: List any affiliations with any agency (as current client, employee/volunteer or consumer) Provide a description of how you demonstrate leadership, expertise, service and/or advocacy pertinent to substance use disorders and addictions. What changes would you like to see implemented to improve prevention, early intervention, treatment and recovery support services in New Jersey?  Provide evidence of how your experience and qualifications demonstrate one or more of the following areas: Knowledge of New Jersey behavioral health systems; Knowledge of prevention, early intervention, treatment and recovery support services; Improving quality of care; Medical linkage; Improving service efficiency; Improving outcome measurement; Increasing available resources; Workforce development; Needs assessment/data; Performance based contracting; Knowledge/experience with administrative service organizations; Integration with primary health care; Improving performance; Utilization management; and/or Improving co-occurring mental health/substance abuse integration. What do you consider to be your area of expertise? Why do you think you will be a good PAC Member? If you are in recovery, do you attest that you have been in recovery for over 5 years? Yes_____ No_____ Would you identify yourself as supporting a family member or loved one who is in recovery? Yes____ No____ County of work: __________________ County of residence: __________________ 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 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 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 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 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 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 ---------------------------------------------------- What is your Gender? :  FORMCHECKBOX  Male  FORMCHECKBOX  Female & Transgender & Non-binary/third gender & Prefer to self-describe & Prefer not to say Race / Ethnicity: (Check all that apply)  FORMCHECKBOX  Asian  FORMCHECKBOX  African American  FORMCHECKBOX  Caucasian  FORMCHECKBOX  H2=\]}~rh^QG^:G:^:h)h0BOJQJ^Jh 6OJQJ^Jh.h.OJQJ^Jh.OJQJ^Jh],OJQJ^Jh)h1=0OJQJ^Jh)h1=05OJQJ\^Jh)h5OJQJ\^J#h)h55CJ OJQJ^JaJ h55CJ OJQJ^JaJ h1=05CJ OJQJ^JaJ #h)h)5CJ OJQJ^JaJ h15CJ OJQJ^JaJ h 65CJ OJQJ^JaJ 2]~  # $ Rr2 & F hhh^h`hgd.$ & F h0^`0a$gdiF;$a$gdiF;gd.gd?$a$gd)   " # C F G X Z m o r  ! $ z   ȻջviXJhv{JB*OJQJ^Jph!hv{Jhv{JB*OJQJ^Jphhv{JhY'OJQJ^Jhv{Jh 6OJQJ^Jhv{Jh1OJQJ^Jhv{Jh1OJQJ^Jh1OJQJ^Jh 6OJQJ^Jhn1nOJQJ^Jh)h,dOJQJ^Jh)h)OJQJ^Jh2iOJQJ^Jh1OJQJ^Jh.OJQJ^Jh)h{?:OJQJ^J     " # {   , V w ͽ|r|rh[NDNrN:h1OJQJ^JhOJQJ^Jh)h(VOJQJ^Jh)h zOJQJ^JhY'OJQJ^JhgpOJQJ^Jh)hT_FOJQJ^Jh)hfOJQJ^Jh],OJQJ^Jh)h1=0OJQJ^Jh)h1=05OJQJ\^Jh)h,d5OJQJ\^Jh)h5OJQJ\^J!hv{Jh,dB*OJQJ^Jph!hv{Jhv{JB*OJQJ^Jph -<=IQGUVOcqrϮŮyih)hb@5OJQJ\^Jh)h*OJQJ^Jh*OJQJ^Jh tOJQJ^Jh(VOJQJ^Jh1OJQJ^Jh OJQJ^Jh)hgpOJQJ^JhY'OJQJ^Jh)h zOJQJ^Jh)h|EOJQJ^JhgpOJQJ^Jh)h(VOJQJ^J%12HI'(XYrs-/0Ÿvl_h)hSOJQJ^JhSOJQJ^Jh(VOJQJ^Jh;4OJQJ^JhbOJQJ^Jh)h|EOJQJ^Jh1OJQJ^Jh)hOJQJ^Jh)h(VOJQJ^Jh)h(V5OJQJ\^Jh)h(VOJQJ\^Jh],5OJQJ\^Jh)h1=05OJQJ\^J$(Yt0q R|}gd*gd.81$7$8$H$^8gdv{J & F hhh1$7$8$H$^h`hgd. & F01$7$8$H$`0gd10Janop   !QWadz{|}ȾժՖՌxxhZMh)h)OJQJ^Jh)h)5OJQJ^Jh)h5OJQJ\^JhFdOJQJ^Jh*OJQJ^JhOJQJ^Jhv{JOJQJ^Jh>|OJQJ^Jh1OJQJ^JhCOJQJ^JhgpOJQJ^Jh-Qh-QOJQJ^Jh-QOJQJ^Jh[OJQJ^Jh 9OJQJ^Jh)hCOJQJ^J IX]` &󭝐vvlvYKhwB*OJQJ^JphDr$jhwB*OJQJU^JphDrhn1nOJQJ^Jh)h1=0OJQJ^Jh)h :OJQJ^Jh],5OJQJ\^Jh)h1=05OJQJ\^Jh.OJQJ^Jh'OJQJ^JhhOJQJ^Jh*OJQJ^Jh2iOJQJ^Jh[hOJQJ^Jh 9OJQJ^JhThhOJQJ^J&bde;ತ|oe[e[eMChwOJQJ^JjhwOJQJU^Jh_OJQJ^Jhb@OJQJ^Jh)hb@OJQJ^JhbOJQJ^Jh)h1=0OJQJ^J!h)h1=0B*OJQJ^Jphh_B*OJQJ^JphhB*OJQJphDrh;6hw0JOJQJ^J$jhwB*OJQJU^JphDrhwB*OJQJ^JphDr!hwhwB*OJQJ^JphDr./01VYZcjuz{|ۿ|n`SI|*OJQJ^Jh)hAOJQJ^Jh)hXyOJQJ^Jh)hXy>*OJQJ^Jh)hxV5OJQJ^Jh)hxVOJQJ^Jh)h?OJQJ^Jh;6hw0JOJQJ^JjhwOJQJU^JhwOJQJ^JhwhwOJQJ^J12#$d~NOT$a$gd$gd{n$^`gdz ^`gd.gd.$a$gd`RH "#$(3MS]bd}~DLNO駚|nZ&h9h5CJOJQJ\^JaJh)h1=0>*OJQJ^Jh)hAOJQJ^J h9hCJOJQJ^JaJh*h*OJQJ^Jh*h1=0OJQJ^Jhy OJQJ^JhbOJQJ^JhzOJQJ^Jh)hOJQJ^Jh*OJQJ^Jh)h1=0OJQJ^JhwOJQJ^JOeq')26?@HLPƼƼӲvii\Rh 6OJQJ^Jh)hOJQJ^Jh)hOJQJ^J&h9h5CJOJQJ\^JaJh'OJQJ^Jh]?OJQJ^JhZ-OJQJ^Jho$OJQJ^Jhy OJQJ^Jh.OJQJ^Jh)hAOJQJ^Jh)h1=0OJQJ^Jh)hA5OJQJ\^Jh)h1=05OJQJ\^JPQSUV "#$068KRm}~ٹ٤vlbTFTFTFTh;4h;45OJQJ^Jh;4h5OJQJ^Jh'OJQJ^JhZ-OJQJ^Jh/h*OJQJ^Jh/hs@UOJQJ^Jh~OJQJ^Jh;4OJQJ^Jhs@UOJQJ^Jh 65OJQJ^Jh)h5OJQJ^J#h)h5CJ$OJQJ^JaJ$h)hOJQJ^Jh)h1=0OJQJ^Jh/h1=0OJQJ^J&:FVabc@]^lm{|@־־־̳̳֚־ug\hh>*OJQJ^Jhn#h9>*OJQJ^Jhn#h9OJQJ^Jh)h9>*OJQJ^Jh9OJQJ^Jhn#>*OJQJ^Jh;4h;4>*OJQJ^Jh;4>*OJQJ^Jh)h>*OJQJ^Jh;4OJQJ^Jh)hOJQJ^Jh;4h5OJQJ^Jh;4h;45OJQJ^J %&EFbc@NO]^gd9$a$gdgd$a$gd$a$gd* hn#>*hn#hn#>*OJQJ^Jhn#>*OJQJ^Jh;4OJQJ^Jhn#hn#OJQJ^Jhn#h>*OJQJ^Jhn#hOJQJ^J(! !u!{!!!!!!!!!/"5"D"F"S"T"U"b"c"d""""#ǹrdZPFh9OJQJ^Jhs@UOJQJ^Jh`%OJQJ^Jh`%h`%>*OJQJ^Jh`%h>*OJQJ^Jh>*OJQJ^Jh`%>*OJQJ^Jhh>*OJQJ^Jh)hOJQJ^Jh>*OJQJ^Jh)h>*OJQJ^Jhn#>*OJQJ^Jh>|OJQJ^Jh)hbYOJQJ^JhbYOJQJ^Jh-QhbYOJQJ^J!!!!!!6"7"E"F"T"U"c"d"""""""""""D#E###dhgds@Ugdgd#(#/#C#D#########$$$$$$%%%&'&&&d'e'''4)5) * *e*y*⪝ud h)hs@UCJOJQJ^JaJh)hs@UOJQJ^JhbYOJQJ^J hhCJOJQJ^JaJh*OJQJ^Jh)hs@UOJQJ^JhOJQJ^J h)hs@UCJOJQJ^JaJ h)hs@UCJOJQJ^JaJhs@UCJOJQJ^JaJ++++,,, ,",V,Z,\,,,,,,--0-2-4-N-P-l-n-p----~jV'j\hIh8}OJQJU^J'jhIh8}OJQJU^J hIhgG' hIhgG'CJOJQJ^JaJ)hIhgG'B*CJOJQJ^JaJph111)hIhgG'B*CJOJQJ^JaJph111hIhgG'OJQJ^JhIh8}OJQJ^J!jhIh8}OJQJU^J'jthIh8}OJQJU^J--------.dd dddd,d-d;d*OJQJ^Jh8}h8}OJQJ^J'j,hIh8}OJQJU^J'jhIh8}OJQJU^JU'jDhIh8}OJQJU^JhIh8}OJQJ^J!jhIh8}OJQJU^J'jhIh8}OJQJU^Jispanic  FORMCHECKBOX  Native American  FORMCHECKBOX  Other ;0P:ps/ =!"#$% DptDeCheck1tDeCheck2tDeCheck5tDeCheck6tDeCheck9tDeCheck7tDeCheck8tDeCheck3s02 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH L`L Normal1$7$8$H$CJ_HaJmH sH tH 22  Heading 1@&22  Heading 2@&22  Heading 3@&22  Heading 4@&22  Heading 5@&22  Heading 6@&2@2  Heading 7@&DA D Default Paragraph FontRiR  Table Normal4 l4a (k (No List HH C Balloon TextCJOJQJ^JaJ6U`6 ? 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Segoe UI Symbol7.*{$ Calibri5. .[`)Tahoma?= .Cx Courier New;WingdingsA$BCambria Math"h##K"CC!xxr%% 3q P?C2! xx DIVISION OF ADDICTION SERVICES Dona Sinton Alicia Meyer$      Oh+'0   @ L X dpx DIVISION OF ADDICTION SERVICES Dona SintonNormalAlicia Meyer2Microsoft Office Word@@nǷ@*@* ՜.+,D՜.+,P  hp  NJDHSC% DIVISION OF ADDICTION SERVICES Titlep 8@ _PID_HLINKSA( zPmailto:alicia.meyer@dhs.nj.govR=https://www.nj.gov/humanservices/dmhas/home/councils/pac.htm  !"#$%&'()*+,-./012356789:;=>?@ABCDEFGHIJKLMNOPQRSTUVWXY[\]^_`acdefghilRoot Entry Fߣ?nData 41Table<4:WordDocument=fSummaryInformation(ZDocumentSummaryInformation8bCompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q