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#24-005477-0002
Supplemental Questionnaire

Last Name
First Name

 

**Please note that your answers on the supplemental questionnaire must correspond to the information provided on your application to receive credit. Applications that do not include a completed supplemental questionnaire will be considered incomplete and may be subject to disapproval.**

 


1

Do you possess a Master's degree in public health, social services, sociology, psychology, or other related field(s)?

Yes No
2

What field of study is your master's degree in?

3

Describe your progressively responsible professional, technical, analytical and developmental work experience.

Please include name of employer, job title, dates of employment, and hours worked per week.  This information must also be reflected in your application.  If you do not possess experience in this area, put N/A in the box below.

4

Describe your experience in a lead/supervisory role.

Please include name of employer, job title, dates of employment, and hours worked per week.  This information must also be reflected in your application.  If you do not possess experience in this area, put N/A in the box below.

5

Do you possess a current certification as a Peer Recovery Specialist from the Maryland Addictions Professionals Certification Board (MAPCB)?  If so please attach a copy with your application.

Yes No
6

Describe your experience working with Peer Recovery Specialists in a lead/supervisory role.

Please include name of employer, job title, dates of employment, and hours worked per week.  This information must also be reflected in your application.  If you do not possess experience in this area, put N/A in the box below.

7

Describe your experience working as a Certified Peer Recovery Specialist.

Please include name of employer, job title, dates of employment, and hours worked per week.  This information must also be reflected in your application.  If you do not possess experience in this area, put N/A in the box below.

8

Describe your experience providing educational instruction in a live and/or virtual setting.

Please include name of employer, job title, dates of employment, and hours worked per week.  This information must also be reflected in your application.  If you do not possess experience in this area, put N/A in the box below.


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