Official SealDepartment of Budget and Management


#19-004256-0002
Supplemental Questionnaire

Last Name
First Name
1.

Do you possess current CPR certification?

Yes No
2.

Do you possess current Pediatrics or Family Nurse Practitioner certification? If yes please be sure to attach a copy of the certification to your application.

Yes No
3.

Do you possess one year of clinical supervision or management?  If so, please provide the dates of employment, name of the employer, job duties and hours worked per week. If you do not have this experience, indicate N/A.

4.

Do you have experience as a nurse practitioner in pediatrics or adolescent health?  If so, please provide the dates of employment, name of the employer, job duties and hours worked per week. If you do not have this experience, indicate N/A.


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