Boards & Commissions Nomination Form

Boards and Commissions Member Recommendations

The Illinois Department of Human Services (IDHS) is committed to advancing equity and racial justice. As an extension of that commitment, we seek to curate and cultivate a workforce that reflects the diversity of the people of Illinois and is representative of the people we serve. This means ensuring diverse representation on all our boards, commissions, task forces, advisory councils, etc., which requires that we create a pool of qualified candidates who represent often underrepresented communities.

This survey/form is designed to gather information to assist us in identifying a diverse slate of potential nominees. The information you provide will be utilized only for the purpose noted here and will not be shared outside the group tasked with making recommendations. We appreciate your response.

Candidate for:

Nominated by: Self Other

Name:

Affiliation:

Degree Completed:

License/Certification:

University/School:

Employer Name:

Employer City:

Employer County:

Residence City:

Residence County:

Military Status: Yes No

Do you currently serve on an IDHS Board or Commission? Yes No

If yes, please provide:

Name of Board/Commission:

Start Date: End Date:

Short Bio (please limit to 250 words or less

Race & Ethnicity:

• African-American/Black
• Arab American
• Asian American & Pacific Islander
• Hispanic or Latina/o/x
• Native American/American Indian
• White/Caucasian
• Other
• Not Identified
• Prefer not to Disclose

Gender: Male Female Other Not Identified Prefer not to Disclose

Disability: Yes, I have a disability No, I do not have a disability Prefer not to Disclose

Experience and/or Interest in the following IDHS Divisions:

• Developmental Disabilities
• Family & Community Services
• Mental Health
• Rehabilitation Services
• Substance Use Prevention & Recovery

Primary/Preferred Language: