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#19-002820-0001
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 a Bachelor's degree in Nursing, Social Work, Psychology, Education, Counseling or a related field?

Yes No
2.

Describe your experience with professional work in health or medical services 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.

3.

Describe your experience working with public health programs.   Include name of employer, job title, dates employed, and hours worked per week.  If you do not have this experience, put N/A in the box below.

4.

Describe your work experience in contract management. In your description please include the name of your employer, dates of employment, job title, and job duties. If you do not have this type of experience, enter N/A.

 


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