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#23-004403-0001
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

Do you possess a Bachelor's degree from an accredited college or university, with thirty credits in Behavioral Science, Health Services, Human Services or Education?

Yes No

 

If yes, please submit a copy of your transcripts showing the required coursework with your application.


2

What is the major field of study for your bachelor's degree? If you answered "No" to the previous question, please enter N/A in the box.

3

Do you possess graduate level education in behavioral sciences, health services, human services or education?

Yes No
4

Describe your experience in counseling alcohol or drug dependent clients; in providing therapeutic education services to alcohol or drug dependent persons and their families; or in directing school or community health education.

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

Describe your experience presenting topics related to substance use prevention to audiences of all ages.

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.

6

Describe your experience conducting training in the disease concepts of addiction.

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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