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#19-001532-0003
Supplemental Questionnaire

Last Name
First Name
1.

Please explain in detail, your experience managing a child welfare prevention program. Please include the name of your employer, job title, dates of employment and hours worked per week. If you do not have this type of experience, please indicate N/A.

2.

Do you have two years of experience using the Maryland Children's Electronic Social Services Information Exchange System (MD CHESSIE)?

Yes No
3.

Are you licensed by the Maryland Board of Social Work Examiners? If yes, please indicate the license level, license number and expiration date. If you do are not licensed by the Maryland Board of Social Work Examiners, please indicate N/A.


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