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#18-002942-0011
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 Bachelor's degree in Nursing, Social Work, Psychology, Education, Counseling or a 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

Describe your professional experience in health services.  Health services is defined as experience in areas other than Mental Health, Developmental Disabilities or Addictions.

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 at the managerial and/or supervisory level, especially in a Psychiatric 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.

5

Describe your experience with cancer prevention and control.  This experience must also be included on your application.  If you do not possess this type of experience, please indicate N/A in the text box below.

6

Describe your experience managing contracts with partners in health systems, local health departments and community organizations.  This experience must also be included on your application.  If you do not possess this type of experience, please indicate N/A in the text box below.

7

Please describe your one year of experience using the Microsoft Office Suite to include Word, Excel and PowerPoint?  Please provide the employer name(s) and dates where you gained this experience.  (If you do not possess this work experience, enter N/A.)


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