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#18-002586-0045
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 posses a Master's degree in Public Health or a related field from an accredited college or university?

Yes No
2.

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

3.

Are you currently a registered dental hygienist?

Yes No
4.

If you answered Yes to the previous question, please provide the license number and expiration date in the box below.  A copy of your current license or license verification should also accompany your application.

5.

Describe your administrative staff or professional work experience.

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 project management experience managing federal grants with specific domain experience in maternal and child oral health.

With your description, include name of employer, job title, dates of employment, and hours worked per week for each relevant position.  This experience must also be reflected in the "Work Experience" section of your application.  If you do not have this experience, put N/A in the box below.


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