Step 4: Submission of Forms Please submit the full, completed Post-Training Packet along with your Personal Statement or Resume to SDMC by one of the following methods:

• Email to SDMCvolunteers@justicecenter.ny.gov;• Fax to 518-549-0460; or• Mail to: NYS Justice Center for the Protection of People with Special Needs

Surrogate Decision-Making Committee, 401 State Street, Schenectady, NY 12305

Surrogate Decision-Making Committee, 401 State Street, Schenectady, NY 12305

ANDREW M. CUOMO Governor

DENISE M. MIRANDA Executive Director

Surrogate Decision-Making Committee 401 State Street, Schenectady, NY 12305

Ph: 518-549-0328 I Fax: 518-549-0460 SDMCVolunteers@justicecenter.ny.gov

• Your contact information, which will be used to contact you regarding service on Hearing panels.• Your availability during the week to attend Hearings.• All counties in which you can serve (see SDMC Regional Map on Page 3)• Panel Position: Each volunteer must indicate the position for which they qualify; please select all

that apply.• Please indicate any Potential Conflicts of Interest such as:

o Family relations with a current SDMC volunteer;o Strongly held personal opinions, which might affect your ability to make an impartial

decision about a medical procedure or treatment; ando Any affiliation with an agency or organization that may utilize SDMC services (This

information will be used to schedule hearings to avoid conflicts of interest).• Signed Attestation of Completion of Volunteer Training and Review of Guidance Materials,

affirming that you have completed all SDMC training requirements.

• Sign the Oath of Office before a notary public.• Sign the Public Officers Law §78 Certificate. This acknowledges receipt of the Public Officers

Law, available for download on the Justice Center Website.

SDMC New Volunteer Panel Member Post-Training Packet

Welcome to the Surrogate Decision-Making Committee!

To conclude your orientation as a new volunteer, please complete Steps 1-4.

Once we have received all of the required post-training documents, SDMC will send you a letter of appointment and provide our regional contractor(s) in your area with your information. The regional contractors will reach out to you regarding specific hearings and can be contacted with questions about the program.

Step 1: SDMC New Volunteer Panel Information Form/Attestation (Page 2)Please take the time to complete the New Volunteer Panel Information form by completing the following:

Step 2: Personal Statement/Resume Please include a personal statement or a resume that provides an overview of your experiences and accomplishments to support qualification for the selected panelist position(s) on the SDMC New Volunteer Panel Information Form/Attestation.

Step 3: Public Officer Oath/Affirmation (Page 4)SDMC volunteers are considered public officers and must comply with Public Officers Law§73, 73a, 74, 75, 76, 77, and 78. Volunteers are required to:

Title: Date:

Mailing Address:

Work Phone:

Fax Number:

Secondary Email:

Employer:

Home Phone:

Cell Phone:

Email:

Counties in which you are able to serve:

Afternoon (12pm-4pm)

Admitted in the 1st 2nd 3rd 4th Dept.

License Number:

Are you employed/affiliated with any agency or organization providing services to individuals with disabilities?

Please return to SDMC by fax, email, or mail to the address listed above. Revised 10/19

ANDREW M. CUOMO Governor

DENISE M. MIRANDA Executive Director

Surrogate Decision-Making Committee 401 State Street, Schenectady, NY 12305

Ph: 518-549-0328 I Fax: 518-549-0460 SDMCVolunteers@justicecenter.ny.gov

Attestation of Completion of Volunteer Training and Review of Guidance MaterialsI hereby attest that I have completed the Surrogate Decision Making Committee Program Volunteer training modules and have read and understand all course material and guidance documents. I understand that I am responsible for complying with the laws, policies and regulations described in these modules.

Signature Date

SDMC New Volunteer Panel Information Form

Name:

Times/Days you are available for SDMC Hearings: Morning (9am-12pm)

Monday Wednesday Thursday Friday

Please check all positions for which you qualify to serve on an SDMC Panel:

Tuesday

Attorney: New York State-licensed Attorney

Medical: New York State-licensed Health Care Professional

Family Member: Parent, spouse, sibling, adult child of person with disability, former service recipientPlease describe your specific role in your personal statement/resume.

Advocate: Person who advocates for the care/treatment of persons with disabilities.

Profession:

Reg.#:

Please describe your experience as an advocate in your personal statement/resume.

Please list any potential conflicts of interest which might affect your ability to make an impartial decision about a medical procedure or treatment, such as a family relation to a volunteer or a strongly-held personal opinion:

Surrogate Decision-Making Committee Regions

The map below illustrates the different SDMC regions, each covered by a Regional Contractor.Volunteers may serve in any counties in which they can attend hearings and can serve in multiple regions.

Surrogate Decision-Making Committee 401 State Street, Schenectady, NY 12305

Ph: 518-549-0328 I Fax: 518-549-0460 SDMCVolunteers@justicecenter.ny.gov

(TYPE ALL INFORMATION -- SIGN IN BLACK INK)

Name of Appointee: (Last Name) (First Name) (Middle Initial)

STATE OF NEW YORK )

) ss.:

COUNTY OF )

I do solemnly swear (or affirm) that I will support the constitution of the United States, and the constitution of the

State of New York, and that I will faithfully discharge the duties of the office of

Title of Position:

Agency Name:

Agency Code:

according to the best of my ability.

X (Signature of Appointee)

Sworn (or affirmed) before me this day

of , in the year, 20 .

Notary Public

*****************************************************************************************************************

PUBLIC OFFICERS LAW §78 CERTIFICATE

I, the Appointee named above, hereby acknowledge receipt of a copy of sections 73, 73-a, 74, 75, 76, 77 and 78 of the Public

Officers Law, together with such other material related thereto as may have been prepared by the Secretary of State, and I

acknowledge that I have read the same and that I undertake to conform to the provisions, purposes and intent thereof and to the

norms of conduct for members, officers and employees of the legislature and state agencies.

X (Signature of Appointee) (Date)

(Appointee must sign both the Public Officer Oath/Affirmation and the Public Officers Law §78 Certificate)

Go to www.dos.ny.gov for filing instructions. DOS-1750-f (Rev. 02/16) Page 1 of 1