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#18-005482-0028
Supplemental Questionnaire

Last Name
First Name

 

Please note that your answer on the supplemental questionnaire must correspond to the information that is provided on your resume to receive credit.


1

Do you possess a Bachelor's Degree in health, human services, criminal justice, business administration or related field?

Yes No
2

What is the major field of study for your bachelor's degree? If you answered "No" to the previous question, please enter N/A in the box.

3

Do you possess a Master's Degree from an accredited college or university?

Yes No
4

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

5

Describe your experience providing health services or overseeing operations in a behavioral health care setting (MH/Addictions/DD) to include experience in program planning, development or quality improvement initiatives.

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.

6

Please describe your supervisory experience.  Include employer name(s), job title(s), dates of employment, and titles of those you supervised.  If you do not possess this experience, enter N/A.


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