Steering Committee Application Suicide Prevention Coalition of Clackamas County

Steering Committee Application for the Suicide Prevention Coalition of Clackamas County

Thank you for your interest in serving on the Steering Committee for the Coalition for Suicide Prevention of Clackamas County.

We estimate that the application will take about 15-30 minutes to complete; unfortunately we don't have the ability to save a partial submission and come back and edit it later. We apologize for the inconvenience.

Please complete the following application to serve on the Steering Committee for the Suicide Prevention Coalition of Clackamas County. If you would like to submit any other relevant information, reference your steering committee application in an email and send your additional information or materials to kturner@clackamas.us. Thank you!

The vision of the Suicide Prevention Coalition of Clackamas County is to develop and help guide implementation of a suicide prevention strategy identifying recommendations, priorities, and action steps toward the goal of zero suicides in Clackamas County, Oregon. The Steering Committee is responsible for general oversight of the Coalition's strategic plan, meetings, activities and associated projects, including planning, implementing, and evaluating activities associated with the Coalition. The Steering Committee develops and implement strategies that lead to long-term involvement of community institutions, organizations and individuals in health promotion, assessment, and evaluation. For additional information about the Coalition and the role of Steering Committee members, please see the Suicide Prevention Coalition of Clackamas County charter.

Time Commitment:

• Approximately 3-5 hours per month
• Attend Steering Committee and Coalition meetings, major Coalition activities and work groups as necessary
• One-year to two-year availability (to ensure smooth leadership transition)

The Steering Committee of the Coalition is appointed by the Coalition sponsors (the Directors of Health, Housing and Human Services and Behavioral Health Division of Clackamas County) for the first two years (through April 2021) for terms between one and two years. Interested parties may apply to become members of the Steering Committee. The sponsors choose the Steering Committee (through at least April 2021). Once the Coalition is established after the first two years, the Coalition will revisit the appointment process in April 2021.

We will treat any information you share with us with sensitivity. We appreciate you sharing your background and experiences with us. There are many roles, professions and backgrounds needed in the pursuit to prevent suicide. Sharing this information will help us build a steering committee with diverse perspectives, experiences and background. Thank you.

If you have any comments or questions, please contact kturner@clackamas.us. Thank you.

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* 1. Please provide the following contact information:

First Name

Last Name

Pronouns

Organization (if applicable)

Employer (if applicable)

Position Title (if applicable)

Address:

City

State

Zip Code

Email Address:

Work Phone:

Home Phone:

Cell Phone:

Organizational Website:

Fax:

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* 2. Generally, we will contact you via email. If we need to contact you by phone, what phone number would you prefer we use to contact you?

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* 3. May we text you on your cell phone?

Yes

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* 4. Why would you like to serve on the steering committee?

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* 5. What lived experience, experience or background do you have that might be significant to the Coalition?

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* 6. If not discussed before, what experience do you have leading dynamic groups in an inclusive manner?

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* 7. Please list other County Boards or Commissions on which you serve or have served. Please share the name of the Commission or Board, your role and the dates you have served. Thank you.

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* 8. Other than County Boards or Commissions, what are other boards, commissions or coalitions you are currently serving on or have recently served on? Please share the name of the entity, your role and the dates served. Thank you.

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* 9. Are you currently employed by Clackamas County?

Yes

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* 10. What is your age?

Under 18

18-24

25-34

35-44

45-54

55-64

65+

Prefer not to say

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* 11. What is your gender?

Male

Female

Non-Binary/Third Gender

Prefer to self-describe

Prefer not to say

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* 12. Do you identify as transgender?

Yes

Prefer Not to Say

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* 13. Are you Hispanic or Latino?

Yes

Prefer not to say

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* 14. What is your race?

American Indian or Alaska Native

Asian

Black or African American

Asian or Asian American

Native Hawaiian or other Pacific Islander

White

Prefer not to say

Another race (please specify)

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* 15. Where do you live and/or work?

Clackamas County

Multnomah County

Washington County

Marion County

Other (please specify)

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* 16. How would you describe your community?

Urban

Small Town

Rural

Other (please specify)

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* 17. Please check any work, home or community roles or experiences that describe you (now or in the past). Thank you.

Suicide Attempt Survivor

Suicide Loss Survivor

I have had thoughts of suicide (now or in the past)

Parent

Grandparent

Caregiver

Aging Services Provider

Business Owner or Staff

Clergy/Pastoral/Chaplain

Faith Community Member

Educator

School Counselor

Firefighter/Rescue/Emergency Medical Technician

Housing/Housing Services Provider

Health Care/Services Provider

Mental Health Professional

Peer Services Professional

Sheriff/Police/Corrections

Social Services Provider (please specify in the "other" box below)

Student

Veteran/Military Service Member/National Guard

Public Health

Grief Support

Veterans Services Provider

Youth Services Provider

Volunteer

Juvenile Justice Service Provider

Hospital Industry

Funeral Industry

Other

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* 18. What else would you like us to know about you, your experiences or your background?

We appreciate you taking the time to apply. Thank you so much for your interest.