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#22-001994-0002
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.

Do you possess a current license as a Certified Social Worker, Clinical (LCSW-C) from the Maryland Board of Social Work Examiners?  If yes, please attach your license.

Yes No
2.

If you answered Yes to the previous question, please provide the license number and expiration date in the box below.  A copy of your current license or license verification should also accompany your application.

3.

Do you have at least four years of experience rendering clinical social work services in a health care or treatment setting subsequent to the receipt of an approved Master's degree in Social Work?

Yes No
4.

If you answered yes, please describe this experience and include job title, dates of employment and hours worked per week. If you do not have this experience, please indicate N/A.

5.

Please indicate the date that you earned your Master's degree in Social Work in the space below (i.e., May 2010). If you do not have a Master's degree in Social Work, put N/A in the space below.

6.

Do you have supervisory experience? If yes, please describe in detail and include name of employer(s) where you gained this experience, dates of employment, and relevant job duties. If no, please enter N/A.

7.

Describe your experience running reports for a health program, organization, etc., to ensure that its billing is accurate and its budget is met.

This experience should be included on your application. If you do not possess this type of experience, please put N/A in the text box.


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