Appendix A: Example of chart detailing team composition. Please include the information you think best communicates why you have assembled
your team. Please limit your overall team to 8 members total.
Overall Team Composition
Name & Title
Co-lead
1. Jane Smith, MPH
State Maternal Death
Review Coordinator
Co-lead
2. John Smith, PhD
MCH Epidemiologist at
Health Department
3. Joe Smith, MD
ACOG Member
Representative
Title V/MCH Program Staff (at least 1 required);
Epidemiology Staff (at least 1 required); Organizational
Partner (at least 1 required); Additional Team members
(up to 8 allowed)
Title V/MCH Program Staff
Epidemiology Staff
Maternal Mortality Review Committee Leadership
Maternal Mortality Review Committee Member
Clinical Organizational Representative
Other
Title V/MCH Program Staff
Epidemiology Staff
Maternal Mortality Review Committee Leadership
Maternal Mortality Review Committee Member
Clinical Organizational Representative
Other
Title V/MCH Program Staff
Epidemiology Staff
Maternal Mortality Review Committee Leadership
Maternal Mortality Review Committee Member
Clinical Organizational Representative
Other
Contact Information
Agency
Address
Email
Phone
Relevant Expertise
Jane is the manager of the maternal death review
under the Title V program at the state health
department.
Agency
Address
Email
Phone
John manages data and surveillance of MCH issues
within the state. He holds an appointment at the
State University in the Epidemiology Program.
Agency
Address
Email
Phone
Joe is a practicing OB-GYN and also serves at the
ACOG representative for the state.
4. Jen Smith, PhD
Nursing Manager at
Hospital
Title V/MCH Program Staff
Epidemiology Staff
Maternal Mortality Review Committee Leadership
Maternal Mortality Review Committee Member
Clinical Organizational Representative
Other
Agency
Address
Email
Phone
Jen is the Nursing Manager at a major birthing
hospital in the area.
5. Jess Smith,
Behavioral Health
Specialist
Title V/MCH Program Staff
Epidemiology Staff
Maternal Mortality Review Committee Leadership
Maternal Mortality Review Committee Member
Clinical Organizational Representative
Other
Agency
Address
Email
Phone
Jess is a Behavioral Health Specialist. She has been
practicing for twenty years.
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6.
7.
8.
Title V/MCH Program Staff
Epidemiology Staff
Maternal Mortality Review Committee Leadership
Maternal Mortality Review Committee Member
Clinical Organizational Representative
Other
Title V/MCH Program Staff
Epidemiology Staff
Maternal Mortality Review Committee Leadership
Maternal Mortality Review Committee Member
Clinical Organizational Representative
Other
Title V/MCH Program Staff
Epidemiology Staff
Maternal Mortality Review Committee Leadership
Maternal Mortality Review Committee Member
Clinical Organizational Representative
Other
Agency
Address
Email
Phone
Agency
Address
Email
Phone
Agency
Address
Email
Phone
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