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#21-000049-0001
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 have a Bachelor's degree in Biochemistry, Biology, Biotechnology, Chemistry, Genetics, Immunology, Microbiology, Molecular Biology, or Medical Technology, from an accredited college or university?

Yes No
2.

Describe your experience working in a medical or public health laboratory performing diagnostic or public health testing on human specimens.

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 participating in Informal Dispute Resolution (IDR) conferences.

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 providing testimony in hearings.

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 experience working in a public health laboratory.

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.


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