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#19-003235-0003
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 in health or clinical background and familiarity with medical terminology. Please include name of employer, job title, dates of employment, and hours worked per week. If you do not have this type of experience, please type N/A in the box below.

2

Describe your experience with worker's compensation, work place safety standards and procedures. Please include name of employer, job title, dates of employment, and hours worked per week. If you do not have this type of experience, please type N/A in the box below.

3

Describe your experience in responding to internal and external customer requests. Please include name of employer, job title, dates of employment, and hours worked per week. If you do not have this type of experience, please type N/A in the box below.

4

Describe your experience handling confidential correspondence, reports for executive level staff in an office setting. Please include name of employer, job title, dates of employment, and hours worked per week. If you do not have this type of experience, please type N/A in the box below.

5

Describe your experience using Microsoft Office Suite (Word, Excel, and PowerPoint for example), Google Suite (Google Sheets, Google Docs, Gmail, Google Calendar, and Google Voice). Please include name of employer, job title, dates of employment, and hours worked per week. If you do not have this type of experience, please type N/A in the box below.


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