Official SealDepartment of Budget and Management


#20-002941-0004
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.

Do you have a Bachelor's degree from an accredited college or university in nursing, social work, psychology, education or counseling?  (This information must be listed on your application in order to receive credit.)

Yes No
2.

In which field of study is your degree? If you do not have a degree, enter N/A.

3.

Do you possess a Master's or Doctoral degree in a health or human services field?

If "yes", please indicate the name of the school where degree was earned, degree type (Master's, Doctoral, etc.), field of study, and the date the degree was earned in the space below.

4.

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.

5.

Describe your health services experience at the managerial or supervisory level. Please include name of employer, job title, titles of those you supervised, 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.

6.

Describe your experience managing grants and working with budgets and tracking expenditures.

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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