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#20-004209-0002
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 working in a residential health care facility.

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.

2

Describe your experience training and leading employees. Please be sure to reflect this experience on your application.

3

If you currently possess a current Certified Nursing Assistant license, then type your CNA license number in the field below.  Please note that you are required to upload a copy of your license with your application.

If you do not have a CNA license, then type "N/A" in the field below.


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