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#23-002941-0006
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.

Describe your professional experience in health services.  Health services is defined as experience 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. 

3.

Describe your health services experience at the managerial or supervisory level. Please include name of employer, job title, titles of those you supervised, 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 experience in a Public Health program.

This experience should be included on your application, including hours and dates worked. If you do not possess this type of experience, please put N/A in the text box.

5.

Describe your experience with equity programming, including addressing disparities and social justice.

This experience should be included on your application, including hours and dates worked. If you do not possess this type of experience, please put N/A in the text box.


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