Official SealDepartment of Budget and Management


#21-001334-0002
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.


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