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#21-001334-0001
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 a Bachelor's degree from an accredited college or university in Nursing, Social Work, Psychology, Education, Counseling or a related field?  If you respond YES to this question, please upload your transcript to the application.

Yes No
2

Describe your professional experience in health services. 

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

Explain your professional work experience related to treatment and services to persons with alcohol or other substance abuse addiction. 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.

4

Describe your knowledge of and/or experience with departmental policy, standard operating procedures and regulations, grant funded activity requirements and/or the continuum of care to meet overarching program goals and service recipient needs.

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

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.


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