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#21-001893-0003
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

Describe your experience in health or human service delivery performing tasks such as program eligibility determination, health screening, client referral services, or nutrition education.

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.

2

Describe your experience with breastfeeding.

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

Bilingual applicants are encouraged to apply.  Are you able to speak, read and write in both Spanish and English? 

Yes No

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