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#21-004201-0001
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 60 credits from an accredited college or university with at least 15 credits in health services, human services, education or the behavioral sciences?  Please note, you must submit your transcript(s) with the application.

Yes No
2.

Describe your experience assisting in the implementation of activity therapy programs under the supervision of a health care professional to include assisting in patient/client assessments for mentally ill patients, aged, or physically ill or physically disabled patients or developmentally disabled clients.

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.

Please describe your experience working with individuals with dementia.

This experience must also be included on your application. Please be sure to include name of employer, job title, dates of employment and hours worked per week. If you do not possess experience in this area, indicate N/A.

4.

Describe your experience interacting on a one-on-one basis with individuals at all functional levels.

This experience must also be included on your application. Please be sure to include name of employer, job title, dates of employment and hours worked per week. If you do not possess experience in this area, indicate N/A.

5.

Describe your familiarity and experience with the use of iPads, Tablets, Computers. Specifically, the use of video chat on multiple formats.


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