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#19-000484-0007
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 possess a Bachelor's degree in Nursing, Social Work, Psychology, Education, Counseling or a related field?

Yes No
2.

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

3.

Describe your experience with professional work in health or medical services in areas, other than Mental Health, Developmental Disabilities or Addictions. 

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.

4.

Describe your professional work experience in the public health system, including experience navigating surveillance systems.

This experience must also be included on your application (please include name of employer, job title, dates of employment and hours worked per week). If you do not possess this type of experience, please indicate N/A.

5.

Describe your experience with identifying and collecting information and critical problem solving with information available.

This experience must also be included on your application (please include name of employer, job title, dates of employment and hours worked per week). If you do not possess this type of experience, please indicate N/A.


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