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#21-000491-0007
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 in Nursing, Social Work, Psychology, Education, Counseling or a related field?

Yes No
2

In which field of study is your degree? If you do not have a degree, enter N/A.

3

Describe your professional experience in health services.  Health services is defined as experience in areas other than Mental Health, Developmental Disabilities or Addictions.

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 professional work experience related to the support services and programs for developmentally disabled clients. 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 working with stakeholders, including providers and coordinators of community services.

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 the Center for Medicare and Medicaid Services (CMS) Community Settings Rule.

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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