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#24-005477-0024
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 have five years of experience working in a human service field, three of which related to older adult care? If yes, please describe this experience including employer names, dates of employment and relevant job duties. This information must also be reflected in your application to qualify. If you do not have this experience, enter N/A.

2.

Do you have experience with budget development? If yes, please describe this experience including employer names, dates of employment and relevant job duties. This information must also be reflected in your application to receive credit. If you do not have this experience, enter N/A.

3.

Do you have experience with legislative advocacy? If yes, please describe this experience including employer names, dates of employment and relevant job duties. This information must also be reflected in your application to receive credit. If you do not have this experience, enter N/A.

4.

Do you have working knowledge of state and/or federal regulations regarding the role of an ombudsman and long term care? If yes, please describe this experience including employer names, dates of employment and relevant job duties. This information must also be reflected in your application to receive credit. If you do not have this experience, enter N/A.

5.

Do you have experience using Microsoft Word, Excel, PowerPoint and Google Suite Applications, i.e, email, sheets, drive, and calendar? If yes, please describe this experience including employer names, dates of employment and relevant job duties. This information must also be reflected in your application to receive credit. If you do not have this experience, enter N/A.


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