Official SealDepartment of Budget and Management


#21-005478-0012
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?

Yes No
2

If you answered Yes to question 1, please list your degree and the name of the college/university in the box below.  If you do not have a Bachelor's degree, please enter N/A.

3

Describe your experience in regulatory compliance, facility surveying, quality improvement or professional work in a health care setting or regulatory agency.

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 at the supervisory or managerial level.

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

5

Describe your prior knowledge of and experience with determining a facility(s) compliance of local, state and federal regulations in a nursing home setting.

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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