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#19-002722-0030
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.**

 


2

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.


3

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?

4

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.

5

Describe your experience working in a high volume office with deadlines and handling multiple duties.

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.

6

Describe experience in which you had to demonstrate strong communication and organizational skills.  Include place of employment, dates of employment and job duties.  If no experience indicate N/A.

7

Describe your analytical ability to gather and interpret data and communicate desired outcomes.

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.

8

Are you flexible/available to work evenings and weekends?

 

Yes No

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