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#22-001362-0010
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 experience with an electronic case management or similar software program? If yes, please include name of employer, job title, dates of employment, and hours worked per week. This information also be reflected in your application. If you do not possess experience in this area, put N/A in the box below

2.

Please describe your professional experience working with individuals with disabilities.  Please describe this experience and including name of employer, job title, dates of employment, and hours worked.  If you do not have this experience please enter N/A in the box below.  

3.

Please describe your experience with medical/disability terminology. Include in your response the name of employer(s) where you obtained this experience, dates of employment, and relevant job duties. This information must also be reflected in your application. If you do not have this experience, enter N/A.


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