Form Membership Nominat Membership Nominat Membership Nomination Form

OMB Control No. 1076-0179
Expiration XX/XXX/20XX

BUREAU OF INDIAN EDUCATION
ADVISORY BOARD FOR EXCEPTIONAL EDUCATION
MEMBERSHIP NOMINATION FORM (20 U.S.C. 1411(h)(6))

Nomination Information

A. Nominations are requested from individuals, organizations, and federally recognized
tribes, as well as from State Directors of Special Education (within the 23 states in which
Bureau funded schools are located) concerned with the education of Indian children with
disabilities as described above. The Membership Nomination form is also accepted from
individuals who would like to self-nominate.
B. Nominees should have expertise and knowledge of the issues and/or needs of American
Indian children with disabilities. Such knowledge and expertise are needed to provide
advice and recommendations to the BIE regarding the needs of American Indian children
with disabilities.
C. A summary of the candidate’s qualifications (resume or curriculum vitae) must be included
with the nomination application. Nominees must have the ability to (1) attend all Advisory
Committee meetings, (2) carry out committee assignments, and (3) participate in
teleconference (live audio or audiovisual) calls and work in groups.
D. The Department of the Interior is committed to equal opportunity in the workplace and
seeks diverse Committee membership, however, is bound by the Indian Preference Act of
1990 (25 U.S.C. § 472).

Objectives and Duties

A. The Board provides guidance, advice, and recommendations with respect to special
education and related services for children with disabilities in BIE funded schools in
accordance with the requirements of P.L. 108-446, the Individuals with Disabilities
Education Improvement Act of 2004 (IDEA 2004) and other relevant federal laws.
B. The Board provides advice and recommendations for the coordination of services within
the BIE and with other local, State, and Federal agencies.
C. The Board provides advice and recommendations on a broad range of policy issues dealing
with the provision of educational services to American Indian children with disabilities.
D. The Board serves as an advocate for American Indian students with special education needs
by providing advice and recommendations regarding best practices, effective program
coordination strategies, and recommendations for improved educational programming.
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E. The Board provides advice and recommendations for the preparation of information
required to be submitted to the Secretary of Education.
F. The Board provides advice and recommends policies concerning effective inter-/intraagency collaboration, including modifications to regulations, and the elimination of
barriers to inter-/intra-agency programs and activities.
G. The Board reports and directs all correspondence to the Assistant Secretary- Indian Affairs
through the Director of the Bureau of Indian Education with a courtesy copy to the
Designated Federal Official (DFO).

Membership

A. The Board shall be composed of fifteen (15) members. The Assistant Secretary – Indian
Affairs may provide the Secretary of the Interior recommendations for the Chairperson.
However, all board members will be appointed by the Secretary of the Interior as required.
Board members shall serve a staggered term of two years or three years from the date of
their appointment. The Secretary may remove members from the Board at any time at
his/her discretion.
B. As required by the IDEA 2004, the Board will be composed of individuals involved in or
concerned with the education and provision of services to Indian children with disabilities.
The Board composition will reflect a broad range of viewpoints and will include at least
one (1) member representing each of the following interests: Indian persons with
disabilities, teachers of children with disabilities, Indian parents or guardians of children
with disabilities, service providers, State Education Officials, Local Education Officials,
State Interagency Coordinating Councils (for states having Indian reservations), Tribal
representatives or tribal organization representatives, and BIA employees concerned with
the education of children with disabilities.
C. Members of the Board will not receive compensation but will be reimbursed for travel,
subsistence and other necessary expenses incurred in the performance of their duties
consistent with 5 U.S.C. § 5703.
D. A member may not participate in matters that will directly affect, or appear to affect, the
financial interests of the member or the member’s spouse or minor children, unless
authorized by the DFO. Compensation from employment does not constitute a financial
interest of the member so long as the matter before the committee will not have a special
or distinct effect on the member or the member’s employer, other than as part of a class.
The provisions of this paragraph do not affect any other statutory or regulatory ethical
obligations to which a member may be subject.
E. The Board meets at least twice a year, budget permitting, but additional meetings may be
held as deemed necessary by the Assistant Secretary or DFO.
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FILL OUT FORM COMPLETELY
Note: Additional pages may be added for further explanation of any item. Reference the corresponding item
number for which the additional explanation is made. Within the published Federal Register notice, the BIE will
direct individuals to the BIE website at https://www.bie.edu/landing-page/special-education within the Special
Education Program, Advisory Board section, where this form will be available for individuals to download a
copy. Submit completed form by email to Jennifer Davis, Designated Federal Officer (DFO) for the BIE
Advisory Board for Exceptional Children, [email protected].

1. Full Name:
2. Personal Mailing Address
(City, State, Zip Code):
3. Primary Phone
(Area code + Number):
4. Secondary Phone
(Area code + Number):
5. Place of Employment:
6. Employment Address
(City, State, Zip Code):
7. Employment Position
Title:
8. Primary Email
Address:
9. Secondary Email
Address:

Note to Review Committee: Prior to submitting this nomination application, the above-named individual
must be contacted regarding appointment to the Advisory Board. Do not make nomination until this person
has been contacted and agreed to have his/her name submitted to the Bureau of Indian Education.

10. If appointed, this person will represent one of the following categories (check all
applicable):
_____

Indian persons with disabilities

_____

Teachers of children with disabilities

_____

Indian parents or guardians of children with disabilities

_____

Service providers

_____

State Education Officials

_____

Local Education Officials

_____

State Interagency Coordinating Councils (for states having Indian reservations)

_____

Tribal representatives or tribal organization representatives

_____

Bureau employees concerned with the education of children with disabilities
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11. What role would you recommend this nominee serve?
_____

Advisory Board Chairperson

_____

Advisory Board Member

12. Nominee’s experience with BIA funded schools: (check all applicable)
_____

BIE Day School

_____

BIE Boarding School

_____

Off-Reservation Boarding School

_____

Tribal Contract School

_____

Tribal Grant School

_____

Cooperative School

13. List nominee’s experiences related to the education of Indian infants, toddler, children,
and youth with disabilities, in the past 10 years. Include time frames of experience or
employment, position titles, location of employment or organization involvement and a
brief description of duties. Attach additional pages if necessary.

14. Identify special interests, activities, awards (professional, educational and community)
related to the education of disabled Indian children (infants, toddler, children and/or
youth). Attach additional pages if necessary.

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15. Identify special interests, activities, awards (professional, educational and
community) related to the education of disabled Indian children (infants, toddler,
children and/or youth). Attach additional pages if necessary.

16. Nominee is recommended:
_____ By an individual, organization, or Indian Tribe.
_____ By him/herself (self-nomination).
17. Name of Indian tribe, organization, or individual (include position title) making this
nomination. (If self-nominating type your Full Name, then complete items 21 and 22).
18. Mailing Address (City, State, Zip Code) of Indian tribe, organization, or individual
making nomination.
19. Primary Phone (Area code + Number) of Indian tribe, organization, or individual
making nomination.
20. Contact Email Address of Indian tribe, organization, or individual making
nomination.
21. Signature of Authorizing Official; or if self-nominating, sign your Full Name.
22. Date of Signature (MM/DD/YYYY):

PAPERWORK REDUCTION ACT STATEMENT
This information is being collected to select individuals to serve on a Federal advisory committee, the BIE Advisory
Board for Exceptional Children. Response to this request is required to obtain a benefit. You are not required to respond
to this collection of information unless it displays a currently valid OMB control number. This information will be used to
determine the eligibility and the ranking of the nominee. Public reporting burden for this form is estimated to average 1
hour per response, including the time for reviewing instructions, gathering, maintaining data, completing, and reviewing
the form. Direct comments regarding the burden estimate or any other aspect of this form to Information Collection
Clearance Officer – Indian Affairs, 1001 Indian School Road NW, Suite 229, Albuquerque, NM 87104.

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