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#24-002941-0001
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 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. 

2

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

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

3

Describe your experience at the supervisory or managerial level.

Please include name of employer, job title, dates of employment, and hours worked per week. If you do not possess experience in this area, put N/A in the box below. 

4

Describe your experience with risk management, including root cause analysis.

This experience must be identified in the Work Experience section of the application, including dates and hours worked and a description of the job duties performed. If you do not possess this type of experience, please indicate N/A in the text box.

5

Describe your experience with quality assurance, including developing auditing tools.

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.

6

Describe your experience utilizing MS Office Suite, including MS Excel at the expert level.

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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