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#20-002819-0003
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 possess a Bachelor's degree in Nursing, Social Work, Psychology, Education, Counseling or a related field?

Yes No
2

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

3

Please outline the work or experience you have which includes support services and programs for individuals with intellectual disabilities and/or other developmental disabilities.  Detail duties and the dates these duties were performed.  Give specific details.

4

Describe your experience conducting investigations and/or surveys to determine if programs and/or services funded by the Developmental Disabilities Administration are complying with State, federal and local policies, regulations and laws.

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.

5

Describe your experience participating in IDR meetings and/or the Mortality Review Committee.

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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