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#24-000484-0003
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 assisting in the coordination of a health-related program or referring people to governmental and private resources.

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.

2.

Do you possess a Bachelor's degree from an accredited college or university?

Yes No
3.

Describe your experience with public health, education and/or communication.

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.

Do you possess certification as a Child Passenger Safety Technician (CPST)? If YES, upload a copy of your certification to the application.

Yes No
5.

Describe your experience working with Microsoft Office Suites (Word, Excel and PowerPoint)

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.


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