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#22-000491-0013
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 in Nursing, Social Work, Psychology, Education, Counseling or a related field?

Yes No
2

In which field of study is your degree? If you do not have a degree, enter N/A.

3

Describe your professional experience in health services.  Health services is defined as experience in areas other than Mental Health, Developmental Disabilities or Addictions.

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 professional work experience related to the support services and programs for developmentally disabled clients. 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.

5

Do you possess personal experience with a family member who has intellectual and developmental disabilities? If so, please describe the experience below.

6

Describe your knowledge of and/or experience with Charting the LifeCourse Framework and the MD Community Practice for supporting families.

This experience must be identified in the Work Experience section of the application, including dates and hours worked and a description of the job duties performed. If you do not possess this type of experience, please indicate N/A in the text box.


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