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#18-001720-0003
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

Please describe your knowledge of or experience with the Maryland Medicaid Waiver, CMS Community Rule, Person Centered Planning and the DDA Policy on Reportable Incidents and Investigations.

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.

2

Describe your experience related to the treatment and development of developmentally disabled clients.  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.

3

Describe your experience at a managerial or supervisory level.  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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