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#19-002722-0003
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.***


1.

Do you possess a bachelor’s degree from an accredited college or university in nursing, social work, psychology, education or counseling?

Yes No

 

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


2.

If you do not possess a bachelor's degree from an accredited college or university in nursing, social work, psychology, education or counseling, in what field is your degree?

3.

Describe your professional experience in health services.

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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