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#18-004212-0001
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 completion of 60 credit hours from an accredited college or university with 15 credit hours in health or human services, education or the behavioral sciences?

Yes No
2

Do you possess an Associate of Arts degree from an accredited college or university with a specialization in the treatment of developmental disabilities in a mental health or closely related curriculum to include a supervised clinical practicum in a developmental disability or similar behavior modification setting?

Yes No
3

Do you possess a Bachelor’s degree from an accredited college or university with a specialization in the treatment of developmental disabilities in a mental health or closely related curriculum to include a supervised clinical practicum in a developmental disability or similar behavior modification setting?

Yes No

4

If you responded YES to any of the above questions, please upload a copy of your transcript(s) to the application.  Unofficial transcript(s) are acceptable.


5

Explain your experience providing residential services in a developmental disability or similar behavior modification 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.

6

Describe your experience supervising residential services staff.

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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