Department of Budget and Management

#19-009009-0008
Supplemental Questionnaire

Last Name
First Name

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.

Do you have knowledge and training in a variety of pediatric orthopedic impairments? If yes, please explain. If no, please write "N/A."

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

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

Do you have a current license as a Physical Therapist? If yes, please submit a copy of your license with your application.

Yes No