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Public Health Council New Member Application, F-03027 (04/2022)

Introduction and Welcome

The primary purpose of the Public Health Council is to advise the Governor, the Legislature, Department of Health Services, and the public in Wisconsin on progress in implementing the state’s 10-year public health plan and coordination of responses to public health emergencies.

The Council consists of 23 members, nominated by the Secretary of the Department of Health Services, and appointed for three-year terms by the Governor. The Council shall include a variety of representatives of:

Health care consumers
Health care providers
Health professions educators
Local health departments and boards
Federally recognized American Indian tribes
Public safety agencies

The Public Health Council is created in Wis. Stat. § 15.197(13), as enacted by 2003 Wis. Act 186. The Council is attached to the Department of Health Services under Wis. Stat. § 15.197(13).

This application aims to collect all the relevant information for the appointment of new Council members to the Public Health Council. The application asks questions pertaining to:

Applicant Contact Information (Name, home address, phone number, email, etc.)
Applicant Qualification Information (Personal & Professional Experience, Current Employer, etc.)

Please take the scope of this application into consideration when answering the following question.

1. Under Wisconsin Statutes 19.36(7)(b), as an applicant for this position, you have the limited right to request that your identity be kept in confidence.

This right prevents your identity from being released in response to a public records request unless; you are appointed to the position or you are a finalist for the position as defined by Wisconsin Statute 19.36(7)(a).

If you wish to preserve this right, you must select "yes" below. *This question is required.

2. First Name: *This question is required.

3. Last Name: *This question is required.

4. If you are or have been known by any other names, please list them here. (Optional)

5. Primary Email Address *This question is required.

6. Home Address *This question is required.

7. Preferred Phone Number (XXX-XXX-XXXX) *This question is required.

8. Based on the image above, which Wisconsin Public Health Regions have you lived or worked in for more than 12 months? *This question is required.

Northeastern Region of Wisconsin (Green)
Northern Region of Wisconsin (Red)
Southeastern Region of Wisconsin (Orange)
Southern Region of Wisconsin (Yellow)
Western Region of Wisconsin (Blue)
Do not know or not sure
Prefer not to respond

9. List any reasonable accommodations you may need in the application process or while serving on the Public Health Council.

10. Select an answer for all of the following. *This question is required.

Space Cell	Yes	No
I have received public health or health care services.	I have received public health or health care services.: Yes	I have received public health or health care services.: No
I am a representative of a federally-recognized Native American Nation.	I am a representative of a federally-recognized Native American Nation.: Yes	I am a representative of a federally-recognized Native American Nation.: No
I provide public health services.	I provide public health services.: Yes	I provide public health services.: No
I provide health care services.	I provide health care services.: Yes	I provide health care services.: No
I provide emergency management or public safety services.	I provide emergency management or public safety services. : Yes	I provide emergency management or public safety services. : No
I am an educator of health care or public health professionals.	I am an educator of health care or public health professionals. : Yes	I am an educator of health care or public health professionals. : No
I am a representative of a public health advocacy organization or agency.	I am a representative of a public health advocacy organization or agency. : Yes	I am a representative of a public health advocacy organization or agency. : No
I am an elected government official.	I am an elected government official.: Yes	I am an elected government official.: No

What type of organization do you provide services for?

For a Local Health Department
For a Community Based Organization
For a State Health Department or Public Health Agency
For a National Public Health Agency
I am currently Retired, or will be Retired within the next year
Not Listed Above — Write in Please enter an 'other' value for this selection.

Select any roles you currently or previously have had while providing public health services.

Local health officer
Public health nurse
Public health educator, specialist, planner or strategist
Registered sanitarian or environmental health specialist
Not listed above — Write in (Required) Please enter an 'other' value for this selection.

What type of organization do you provide services for?

Private practice
Group practice
Health maintenance organization
Hospital-based organization
I am currently retired or will be retired within the next year
Not listed above — Write in Please enter an 'other' value for this selection.

Select any roles you currently or previously have had while providing health care services.

Primary care provider
Nursing care provider
Specialty care provider
Mental health care provider
Licensed pharmacist
Not listed above — Write in Please enter an 'other' value for this selection.

For what type of organization do you provide services?

Emergency medical service agency
Violence prevention agency
Fire prevention and protection agency
Law enforcement agency
I am retired or will be retired within the next year
Not listed above — Write in Please enter an 'other' value for this selection.

What type of health professions educator are you?

I am a public health professions educator
I am a health care professions educator
I am a retired health professions educator or will be retired within the next year
Not listed above — Write in Please enter an 'other' value for this selection.

Specify your current role and affiliation/agency.

Answer the following to the best of your ability.

11. What lived or personal experiences make you feel like you would be a good candidate to serve on the Public Health Council?

Some examples include background, knowledge, skills, abilities, personal qualities, or any other personal factors. *This question is required.

12. What professional experiences make you feel like you would be a good candidate to serve on the Public Health Council?

Some examples include technical knowledge, training, professional licenses and certifications, or any other professional factors. *This question is required.

13. Why do you want to serve on the Public Health Council?

14. The Public Health Council is an active body that can require the completion of work outside of regularly scheduled Council meeting, and can require Council members to take on a leadership role over the course of their appointment. Some examples of leadership positions on the Public Health Council may include:

Serving on the Council Executive Committee.
Serving as a chair or co-chair of a Council Subcommittee.
Completing singular or reoccurring tasks or acting as a representative for the Council in other spaces or meetings.

Are you willing and able to complete Council related tasks between meetings and serve on in a leadership role on the Council regarding issues you are interested in, after a period of mentoring and familiarization with Council activities and processes?