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#18-002572-0041
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

Describe your experience with medical staff credentialing and re-credentialing and designing and maintaining a credentialing process in conformance with Joint Commission Standards.  This experience should also be included in your application.  If you do not possess this type of experience, please indicate N/A in the text box.

2

Please describe your experience with performing secretarial or clerical work involving typing.  Include details pertaining to software applications/computer use, job title, employer name, dates of employment, and hours worked per week (this information must be reflected on your application in the Work Experience section, to receive full credit). If you do not have this experience, please indicate N/A.


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