The Ohio Suicide Prevention Foundation
2323 West Fifth Avenue, Suite 160, Columbus, OH 43204
614-429-1528

The Vision of Ohio’s Suicide Prevention Foundation is…

To promote suicide prevention as a public health issue and advance evidence-based awareness, intervention, and methodology strategies that will support priority populations and healthy communities.

The Mission of Ohio’s Suicide Prevention Foundation is…

By 2016, through the leadership and stewardship of OSPF, Ohio will have culturally appropriate and strongly supported local capacity for prevention and reduction of suicides and will promote and emphasize statewide efforts for suicide reduction and prevention services for Ohioans throughout their lifespan.

Board of Directors Application

Personal Information
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Disclosure

State and Federal Law and Article IX. Section 3 of the Code of Regulations of The Ohio Suicide Prevention Foundation requires the disclosure of any potential conflict of interest relationships by its Directors. Disclosure is required when the Director: (a) has a personal interest, whether direct or indirect (defined for the purposes of the Foundation’s Code of Regulations as a spouse, or domestic partner, parents, children, siblings and in-laws), in the institution or agency; (b) is employed by the institution or agency; (c) has a personal financial interest in the any proposal before the Foundation, whether direct or indirect; (d) serves as an officer, employee or member of the governing body of any other institution or agency which has an interest in any proposal before the Foundation, whether direct or indirect. Directors are required to complete an annual disclosure form

A potential conflict of interest relationship does not exclude a candidate from consideration as a Director of the Foundation, but disclosure is required and adherence to the reporting requirements contained within the Code of Regulations is mandated.

Disclosure
Organization: Relationship:
Describe Potential Conflict of Interest:
Organization: Relationship:
Describe Potential Conflict of Interest:

Please share with the search committee the reason for your personal interest in serving on the Board of Directors of The Ohio Suicide Prevention Foundation. Please include your personal story, professional skills, experiences or other expertise that will enhance the work of the Board in achieving the mission of the Foundation.

Why do you wish to be a member of the Board of Directors?

I affirm that the information contained within this application is accurate to the best of my knowledge:

______

Signature Date

1