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#19-009009-0008
Supplemental Questionnaire

Last Name
First Name
1

Please indicate your American Sign Language skill level

a. Polite (able to greet and exchange pleasantries; indicate or understand an emergency)
b. Literate (understands a conversation and can respond)
c. Fluent (is your native language or can converse in the language as if it was your native language.)
d. Do not speak sign language.
2

Do you have knowledge and training in sensory processing disorders and treatment? If yes, please explain. If no, please write "N/A."

3

Do you have experience working in an educational placement? If yes, please explain. If no, please write "N/A."

4

Do you have awareness and knowledge about bilingual deaf education and deaf culture? If yes, please explain. If no, please write "N/A."

5

Do you have a current license from the Maryland State Board of Occupational Therapy Practice? If yes, please submit a copy of your license with your application.

Yes No

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