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#21-002722-0049
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 in nursing, social work, psychology, education or counseling?

Yes No
 

If you responded YES to the above question, what field is your Bachelor's degree in?

2.

If you do not possess a bachelor's degree from an accredited college or university in nursing, social work, psychology, education or counseling, in what field is your degree?

3.

Describe your professional experience in health services.

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.

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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