disclosures: 03a5ee61d367071787d3a087051546416e2b96521fe858bd20924afd7b4962d4
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| 03a5ee61d367071787d3a087051546416e2b96521fe858bd20924afd7b4962d4 | 2023/Pospisil_Tanya_4.18.23_CMR_6.07.pdf | 2023 | Tanya Pospisil | Tewksbury Hospital Department of Public Health | DISCLOSURE BY STATE EMPLOYEE OF FINANCIAL INTEREST IN A CONTRACT TO PROVIDE SOCIAL SERVICES RECEIVED PURSUANT TO 930 CMR 6.07 STATE ETHICS COMMISS STATE EMPLOYEE INFORMATION 2023 APR 18 PM Name of state employee: Tanya Pospisil Title/ Position: Director of Psychology medical Services Tewksbury Hospital Agency/Department: Tewksbury Hospital Department of Public Health Agency Address: 365 East Street Tewksbury mA 01876 Office phone: 978-851-7321 2233 Office e-mail tanya.pospisil@mass.gou I am a state employee, and I seek to have a financial interest in a contract or agreement made by a state agency listed below, or by a provider or organization funded by a state agency listed below: A state agency within the following Executive Offices: Executive Office of Health and Human Services, including the Human Service Transportation Office; Executive Office of Public Safety and Security, Executive Office of Elder Affairs, Executive Office of Veteran's Services, or A sheriff's office. The purpose of the contract is: - To provide personal services to a person or persons who receive services from, or have services paid for by, these state agencies; or - To provide educational services to people who work for these state agencies or for providers or organizations funded by these state agencies. I seek approval of the arrangement from the agency for which I serve as a state employee and from the state agency above that made the contract. FINANCIAL INTEREST IN A CONTRACT WITH A STATE AGENCY PLEASE CHECK OFF ONE OF THE THREE STATEMENTS BELOW AND PROVIDE THE REQUESTED INFORMATION. 1) Service to a state agency I will provide personal or educational services to a state agency listed above. Please identify the state agency and also the Executive Office it is in, if applicable. Executive office of Health and Human Services Department of Developmental Services 2) Service to a provider or I will provide personal or educational services to a provider or organization funded by a state organization agency listed above. Please provide the name and address of the provider or organization. Please identify the state agency that funds the provider or organization, and also the Executive Office it is in, if applicable. 3) Service to a person or persons I will provide personal services directly to a person or persons who receive services from, or have services paid for by, a state agency listed above. Please identify the state agency that provides services to, or pays for services for, the person or persons, and also the Executive Office it is in, if applicable. Please describe the Please provide information about the type of personal or educational services you will provide. services you will Please do not include the name of any individual who receives services. provide. The Department of Developmental Services (DDS) is Seeking psychologists to review DDS eligibility packets received from families /individuals interested in becoming eligible for DDS services. What will you be Please include a dollar amount, if possible. paid, or what other financial interest will Hourly rate of $81.00 you have? Employee signature } Tanya Pospisil PhD. Date: 4/3/2023 APPROVAL BY AGENCY YOU SERVE AS A STATE EMPLOYEE Name and title of appointing authority Ridnad M, CMO Office phone 978-851-7321 X 1992450 Office e-mail Signature by By signing richardh.me@gmail.gov here, I indicate that have reviewed the facts that the state employee has appointing authority disclosed above and approve the arrangement proposed by the state employee. h Date: 4/5/23 APPROVAL BY AGENCY THAT MADE THE CONTRACT (IF DIFFERENT) Name and title of person giving DDS Northeast Region birector of Ashley Boyd Fermin approval at the state agency that made Clinical services the contract Office phone 351-426-0173 Office e-mail ashley.boydfermin@mass.gov Signature by person By signing here, I indicate that I have reviewed the facts that the state employee has giving approval disclosed above and approve the arrangement proposed by the state employee. ashey mBord Fen Date: 41712003 Attach additional pages if necessary. File with: State Ethics Commission One Ashburton Place, Room 619 Boston, MA 02108 Form revised February, 2012 | 2023/Pospisil_Tanya_4.18.23_CMR_6.07.pdf |