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#21-003642-0013
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 two years of experience in designing and conducting epidemiological studies and investigations for disease surveillance as an epidemiologist subsequent to receipt of your Master’s degree?

Yes No
2

Describe your experience designing and conducting epidemiological studies and investigations for disease surveillance as an epidemiologist subsequent to the receipt of your Master's degree.

Please include name of employer, job title, dates of employment, and hours worked per week for each relevant position.  If you do not have this experience, put N/A in the box below.

 

3

Describe your experience working in a local or state health department.

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 experience with data collection, analysis, and presentations.

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.

5

Describe your experience in the field of Sexually Transmitted Infections (STI's), most notably Syphilis and Congenital Syphilis.

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.

6

Describe your experience with quality improvement and quality assurance activities.

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.

7

Describe your experience in PRISM, REDCAP, MAVEN, and/or CAREWARE.

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.


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