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#20-002818-0019
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

 

If you responded YES to the above question, please upload a copy of your transcript(s) to the application.  Unofficial versions of transcript(s) are acceptable.


2

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.

3

Describe your experience working with children and adults with developmental disabilities.

With your description, include name of employer, job title, dates of employment, and hours worked per week for each relevant position.  This experience must also be reflected in the "Work Experience" section of your application.  If you do not have this experience, put N/A in the box below.

4

Describe your knowledge of and/or experience with the various services that are funded under the Developmental Disabilities Administration.

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 knowledge of and/or experience with government entitlements such as Supplemental Security Income (SSI) and Medical Assistance (MA), etc.

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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