Revised by DSHS Division for Regional and Local Health Operations, October 29, 2021
Instructions for Completing and Filing the Statement of Elected/Appointed Officer
NOTE: This form must be completed and signed by the newly appointed Health
Authority BEFORE the Oath of Office and Certificate of Appointment forms can be
completed and filed.
GENERAL INFORMATION
ALL information must be typed or written legibly.
This document may be sworn to before anyone authorized by
Texas Government Code §
602.002 to administer oaths and affidavits. Commonly used officials include notaries public
and judges. The seal of the person administering the oath should be visible. If the person
is a notary public,
Texas Government Code § 406.013 requires that the seal be affixed in a
way “that legibly reproduces the required elements of the seal under photographic
methods.”
COMPLETION OF THE STATEMENT OF ELECTED/APPOINTED OFFICER FORM
Upon making the sworn statement, the newly appointed Health Authority must enter their
full name on the appropriate line, and enter the required signature, office to which
appointed, and city/county to be served. The official witnessing the oath should complete
the date the sworn statement is taken, and then enters their signature, printed name and
title. The seal of the appointing official should be affixed in the area designated.
FILING OF THE STATEMENT OF ELECTED/APPOINTED OFFICER
Once the Statement of Elected/Appointed Officer has been completed and signed by both
the Health Authority and the administering official, a copy should be mailed to the Regional
Medical Director for the respective Public Health Region of the Texas Department of State
Health Services ("DSHS").
Please direct any questions regarding this Statement of Elected/Appointed Officer form
and instructions to your DSHS Public Health Region office or to the DSHS Division for
Regional and Local Health Operations office in Austin at (512) 776-7770 or
Pursuant to Tex. Const.
Art. XVI, §1(b). Revised by DSHS Division for Regional and Local Health Operations October 29, 2021
.
THE STATE OF TEXAS
Statement of Elected/Appointed Officer
(Please type or print legibly)
I ____________________________________________________ do solemnly swear (or
affirm) that I have not directly or indirectly paid, offered, promised to pay, contributed, or
promised to contribute any money or thing of value, or promised any public office or
employment for the giving or withholding of a vote at the election at which I was elected
or as a reward to secure my appointment or confirmation, whichever the case may be, so
help me God.
__________________________________________
Affiant’s Signature
__________________
________________________
Printed Name
__________________________________________
Position to Which Elected/Appointed
__________________
________________________
City and/or County
SW
ORN TO and subscribed before me by affiant on this _____ day of _____________ 20___.
__________________________________________
Signature of Person Authorized to Administer
Oaths/Affidavits
(Seal)
_________
_________________________________
Printed Name
__________________
_________________
Title
Revised by
the DSHS Division for Regional and Local Health Operations, October 29,
2021
Instructions for Completing and Filing the Oath of Office
EXECUTION OF THE OATH OF OFFICE
Pursuant to Texas Constitution art. XVI, § 1
(b) and (c), the Oath of Office may not
be taken until a signed Statement of Elected/Appointed Officer has been completed
and filed.
ADMINISTRATION OF THE OATH OF OFFICE
The Oath of Office may be administered by anyone authorized under the provisions
of Texas Government Code § 602.002
. Commonly used officials include notaries
public and judges.
The seal of the person administering the Oath should be visible. If the person is a
notary public, Texas Government Code § 406.013
requires that the seal be affixed in
a way “that legibly reproduces the required elements of the seal under photographic
methods.”
COMPLETION OF THE OATH OF OFFICE FORM
After the Oath of Office has been administered by a properly designated official, the
newly appointed Health Authority should enter their name in the appropriate area of
the form, sign the form and enter their mailing address and telephone number. The
person administering the oath should then enter the date on which the oath was
administered, enter their signature, printed name and title. The seal of the person
administering the oath should be affixed in the designated area of the form.
FILING OF THE OATH OF OFFICE
Once the Oath of Office form has been completed and signed by both the Health
Authority and the administering official, a copy should be mailed to the
Regional Medical Director for the respective Public Health Region of the Texas
Department of State Health Services ("DSHS").
Please direct any questions regarding the Oath of Office form and instructions
to your DSHS Public Health Region office or to the DSHS Division for Regional &
Local Health Operations office in Austin at (512) 776-7770 or [email protected].
Revised by DSHS Division for Regional and Local Health Operations, October 29, 2021
OATH OF OFFICE
For
Health Authorities in the State of Texas
I, _____________________________________________, do solemnly swear (or
affirm), that I will faithfully execute the duties of the office of Health Authority
(HA) of the State of Texas and will to the best of my ability, preserve, protect, and
defend the Constitution and laws of the United States and of this State, so help me
God.
________________________________________
Affiant*
________________________________________
Mailing Address* ZIP*
________________________________________
Phone Number (Emergency/After Hours)*
________________________________________
Email Address (Official, if you have one)*
SWORN
TO and subscribed before me this _______ day of __________________, 20___.
__________________________________________
______
Signature of Person Administering Oath
__________________________________________
______
(Seal)
Printed Name
__________________________________________
______
Title
_________________________________________
Preferred Name (e.g. "J. Paul Doe")
_________________________________________
Texas Medical License Number*
_________________________________________
Are you a deputy/backup HA?
_________________________________________
Additional Email Address
*=denotes required field
Certificate of Appointment
for a
Health Authority
The Health Authority has been appointed and approved by the:
(Put an "X" by the appropriate designation below)
_____Com
missioners Court for _____________________________________ County
_____G
overning Body for the Municipality of _______________________________
_____Di
rector, ________________________________________ Health Department
_____Director, _______________________________________Public Health District
I, _________________________________________________________, acting in my capacity
as: (Put an "X" by the appropriate designation below)
_____Cou
nty Judge or Designee
_____Mayor or Designee
_____Non-physician and the Local Health Department Director
_____Non-physician and the Public Health District Director
do h
ereby certify the physician, _______________________________________, who is licensed
by the Texas Board of Medical Examiners, was duly appointed as the (check as applicable),
_____ Health Authority
_____ Health Authority Designee
for the jurisdiction of ________________________________________________________, Texas.
Date
term of office begins _____________________, 20___
Date term of office ends _____________________, 20___, unless removed by law.
I certify to the above information on this the
________
day of ___________________, 20__.
______________________________________________
Signature o
f Appointing Official
Revised by DSHS Division of Regional and Local Health Operations, October 29th, 2021
