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#21-004884-0001
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

Explain your experience in work assisting in the care, treatment, or rehabilitiation of a developmentally disabled, mentally ill, physically ill, or aged individuals in treatment facility or community based programs. 

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.

2

Describe your experience providing security in an environment with intellectually disabled individuals.

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.

3

Describe your experience with a forensic population.

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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