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#21-002587-0022
Supplemental Questionnaire

Last Name
First Name
1.

Do you have one year of experience implementing or evaluating healthcare or emergency medical service programs?  If yes, please describe your experience.  Include employer, duties and dates of employment.  If no experience, indicate NA.

2.

Describe your experience in a leadership role in a public safety EMS agency?  Include employer, job title, duties and dates of employment.  If no experience, indicate N/A.

3.

Do you possess a current paramedic license/certification?

Yes No

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