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Human Capital Management
#190513-H21A-32


Supplemental Questionnaire

Last Name First Name
 
 

*Intellectual Disability (ID) means a person, per Section 1408 of Title 10 of the Oklahoma Statutes who has significantly sub average functioning, an intelligence quotient (IQ) of less than 70 that manifests before 18 years of age. 

*Developmental disability means a severe chronic disability of a person that is attributable to a mental or physical impairment or combination of mental and physical impairments and is manifested before the person attains 22 years of age.

I have read and understand the above definitions.

Yes No
 

Do you have any of the following?

a bachelor's degree in a human services field AND one year of experience working directly with persons with intellectual and/or developmental disabilities.
possession of a valid permanent Oklahoma license as approved by the Oklahoma Board of Nursing to practice professional nursing AND one year of experience working directly with persons with intellectual and/or developmental disabilities.
none of the above

 

OK Department of Human Services (DHS) requires that the following questions be answered before continuing with the application.


 

Do you have legal status to work in the United States?

Yes No
 

Have you had a protective order entered against you pursuant to the Oklahoma
Protection from Domestic Abuse Act or a similar statute of another state? 

If yes, provide the name of the court and court number in the text area:

If no, please enter No in the text area:            

 

DHS policy does not allow some family members to be employed within the same supervisory group or unit. Please list the names of all of your relatives now employed by DHS:

If no, please enter No in the text area:

 

Have you ever been terminated or resigned from employment in lieu of being terminated?  
If yes, explain circumstances:      

If no, please enter No in the text area:


 
STOP! You have completed the required screening questions for this Job Family.  Please verify you meet the education and experience requirements listed in the job bulletin before completing the following supplemental questionnaire. The questions below will be used for scoring in lieu of a written exam.

1.

What work experience do you have managing caseloads?

I have performed this task as a regular part of my job.
I am familiar with this task or have received some training on it.
I have no experience with this task.
 

Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 

2.

What work experience do you have providing services to individuals with intellectual and/or developmental disabilities? (Check all that apply.)

I have provided assistance to individuals in their homes.
I have provided assistance to individuals in their education or employment setting.
I have provided assistance to individuals in a community setting such as leisure activities, social activities, or shopping.
I have provided direct professional services such as therapy, nursing, or social work.
I have provided assistance to individuals through phone contacts.
I have advocated for services and/or supports for individuals.
I have processed online applications for individuals.
I am familiar with this task or have received some training on it.
I have no experience with this task.
 

Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 

3.

Do you have work experience facilitating or leading meetings?

I have performed this task as a regular part of my job.
I have performed this task occasionally as part of my job.
I have no experience with this task.
 

Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 

4.

What work experience do you have implementing or monitoring services for individuals with intellectual and/or developmental disabilities?

Performing this task was a major part of my job.
Performing this task was a minor part of my job duties.
Performing this task was not part of my job duties.
 

Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 

5.

What is your work experience identifying the needs of and coordinating services for individuals with intellectual and/or developmental disabilities?

I have identified needs and coordinated services for individuals.
I have only identified needs of individuals.
I have only coordinated services for individuals.
I have no experience with this task.
 
Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 
6.

What work experience do you have referring individuals with intellectual and/or developmental disabilities to community resources such as food, clothing, or utility assistance, or low cost/free medical or dental services?  (Check all that apply.)

I have assisted individuals in obtaining services from these resources.
I have researched and identified community resources.
I have provided this information to individuals.
I have no experience with this task.
 
Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below.