Lifeline Committee Nomination Form

 
The Lifeline receives ongoing consultation from three advisory bodies: a Steering Committee, the Consumer-Survivor Subcommittee, and the Standards, Trainings and Practices Subcommittee. These committees were established in order to facilitate continuous feedback from stakeholders regarding project activities and to help create community ownership of this national project to prevent suicide. Over the past eight years, these committees have been critical to Lifeline’s success and have, in many ways, exceeded our expectations.

We are delighted to open a call for nominations to the National Suicide Prevention Lifeline's advisory committees. Please fill the following form to nominate yourself or someone else. The deadline to submit nominations is Friday December 11, 2015.

Question Title

* 1. Are you nominating yourself or someone else?

Question Title

* 2. Your First Name

Question Title

* 3. Your Last Name

Question Title

* 4. Your Affiliation

Question Title

* 5. Your Address

Question Title

* 6. Your City

Question Title

* 7. Your State

Question Title

* 8. Your Zip Code

Question Title

* 9. Your Phone Number

Question Title

* 10. Your Email Address

Question Title

* 11. Has the nominee been notified of your nomination?

Question Title

* 12. Nominee First Name

Question Title

* 13. Nominee Last Name

Question Title

* 14. Nominee Affiliation

Question Title

* 15. Nominee Address

Question Title

* 16. Nominee City

Question Title

* 17. Nominee State

Question Title

* 18. Nominee Zip Code

Question Title

* 19. Nominee Phone Number

Question Title

* 20. Nominee Email Address

Question Title

* 21. For which committee are you nominating this person?

Question Title

* 22. Describe your/nominee's background in suicide prevention and mental health advocacy.

Question Title

* 23. Describe the skills and knowledge that you/nominee will bring to the specific committee you chose.

Question Title

* 24. List your/nominee's commitments to other organizations, including board membership, advisory committees, and coalitions. Include any knowledge of time commitments and whether these will hinder availability for Lifeline committee activities.

Question Title

* 25. Describe your/nominee's other interests as they relate to the Lifeline's mission, values and goals.

Question Title

* 26. The Steering and Subcommittees each hold one two day face-to-face meeting and a minimum of one conference call annually. These meetings are planned months in advance and attendance typically requires arriving in the DC area the evening prior to the meeting. All travel expenses are covered. As these meetings  are only held once a year, it is important to consider availability when considering this application. The following are the established dates for 2016 meetings - please indicate availability for the committee to which you/nominee is applying:

T