Board of Health Nominations Logging
Instructions

Kentucky Department For Public Health

Term Beginning:
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Term Ending:
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The Kentucky Department for Public Health is exploring ways to improve and streamline processes for the Local Health Departments and their partners. As a result, we are launching the electronic submission of the Kentucky Board of Health Nomination form for the appointment and/or re-appointment to a LHD Board of Health.


This online registry is managed by the Division of Administration and Financial Management, Local Health Personnel Branch and all information is stored and confidential within the Cabinet for Health and Family Services.


As stated in KRS 212.020, the members of the local board shall hold office for a term of two (2) years with the terms of physicians, dentists, pharmacists, and fiscal court appointees beginning on January 1st during even-numbered years and the terms of nurses, engineers, optometrists, veterinarians, and consumer lay appointees beginning on January 1st during odd- number years.


Please complete the form below and be sure to fill out any field you see with a red asterisk * as this information is required.


Once you complete the form and hit the Submit button provided at the bottom, you will be prompted to upload any documents that pertain to the nomination. Click the Upload button once you have selected the document you wish to upload.


Please do not change anything that is in the section marked for DPH administrative use only. This may result in the form not being submitted properly.


Please contact the name listed below if you have any questions.


Brandi Hawkins

(502) 564-6663 x4110

brandin.hawkins@ky.gov

General Information
Prefix:
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First Name:
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Last Name:
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Address:
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City:
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State:
Zip:
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County of Legal Residence:
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Home Phone:
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Email:
Employment Information
Place of Employment:
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Phone:
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Do you or your employer have a contract(s) with any county health department?

Representative Type:
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If professional- please provide your Kentucky License Number. Professional representatives must be licensed and practicing.

Kentucky License Number:
Are you currently serving as an elected member of a School Board?
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State officials, members of the General Assembly, superintendents of school districts, and members of local boards of education are not eligible for appointment to local boards of health. Such positions are considered incompatible under KRS 61.080.

Appointment:
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If Reappointed, Time Served:
Demographic Information

Certain demographic information is essential to assure compliance with the Civil Rights Act of 1964 and state administered programs using federal funds. Other information is needed to assure that each board is diversely representative of Kentucky’s citizens.


Race:
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Age:
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Gender:
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THE CABINET FOR HEALTH AND FAMILY SERVICES DOES NOT DISCRIMINATE ON THE BASIS OF RACE, COLOR, NATIONAL ORIGIN, SEX, RELIGION, AGE OR DISABILITY IN MAKING APPOINTMENTS TO BOARDS AND COUNCILS.

Submission Information
Date Submitted
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Submitted By:
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Agency/Organization:
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For DPH administrative use only.

Nomination Reviewed:
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