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#21-004216-0056
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.

Please explain in detail, your experience in community nursing. Please include the name of your employer(s), job title, dates of employment and hours worked per week. If you do not have this type of experience, please write N/A.

2.

Please explain in detail, your experience providing supervision to CNA staff. Please include the name of your employer(s), job title, dates of employment and hours worked per week. If you do not have this type of experience, please write N/A.

3.

Please explain in detail, your experience providing basic nursing skills training to CNA staff. Please include the name of your employer(s), job title, dates of employment and hours worked per week. If you do not have this type of experience, please write N/A

4.

Please describe in detail, your experience using Microsoft Platform and Google Suite. Please include the name of your employer(s), job title, dates of employment and hours worked per week. If you do not have this type of experience, please indicate N/A.


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