Official SealDepartment of Budget and Management

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.**



Describe in 1-3 paragraphs, your experience in providing information on health care and disease prevention within the community.

Do not copy and paste from your resume. 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.


Do you possess any of the following certificates? If so, please indicate what certificate(s) you possess in the text box. You may also upload the certificate(s) to the application.

-Ninety-hour (90) Early Childhood Education certificate
-Forty-five hour (45) Infant Toddler certificate 
-Cardiopulmonary Resuscitation (CPR) and First Aid certification

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