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#19-004394-0004
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

Describe your experience determining eligibility for governmental assistance programs. 

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 in interpreting and applying Medicaid policies and regulations.

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 using MS Word and Excel to create, update, edit documents, charts, reports.

This experience must also be included on your application (please include name of employer, job title, dates of employment and hours worked per week). If you do not possess this type of experience, please indicate N/A.


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