Department of Budget and Management

#21-001328-0006
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.***

1a.

Do you have one year of experience creating and maintaining patient medical records?

Yes No

1b.

If yes, please describe, including employer name(s) and dates of employment. (If you do not possess this experience, enter N/A.)

2a.

Do you have six months of experience working in a department/unit with children?

Yes No

2b.

If yes, please describe, including employer name(s) and dates of employment. (If you do not possess this experience, enter N/A.)

Department of Budget and Management

#21-001328-0006 Supplemental Questionnaire

#21-001328-0006
Supplemental Questionnaire