offical seal
Human Capital Management
#200113-X20A-01


Supplemental Questionnaire

Last Name First Name
 

 

ATTENTION!

Please verify that 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 purposes in lieu of a written exam.


1.

What experience do you have conducting a needs assessment with community partnerships to determine appropriate theoretical basis to initiate programmatic and strategic planning?

I have performed this task independently as a part of my job.
I have performed this task as part of my job with assistance.
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 experience do you have implementing evidence based health education curricula?

I have performed this task independently as a part of my job.
I have performed this task as part of my job with assistance.
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.

What experience do you have evaluating the effectiveness of health education or promotion programs?

I have performed this task independently as a part of my job.
I have performed this task as part of my job with assistance.
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. 
4.

What experience do you have writing and submitting grant proposals and related documents?

I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with assistance.
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. 
5.

Please check all experience you have establishing and maintaining partnerships with agencies, communities, or organizations to determine the need for specialized health education programs.

I have been involved with community partnerships to determine a need for health education programs.
I have been involved with partnerships in planning health education programs.
I have experience implementing and evaluating specialized health education programs.
I have developed health education programs with partnerships that have been sustained over time.
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 experience do you have preparing and delivering public presentations?

I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with assistance.
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. 
7.

What experience do you have facilitating or leading meetings?

I have facilitated or led meetings at least once a month.
I have facilitated or led meetings a few times a year.
I have facilitated or led meetings on a few occasions.
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. 
8.

Are you a Certified Health Education Specialist (CHES)?

Yes No
 
Please list your current certification number below or type N/A if the above answer was No.
9.

What experience do you have conducting classes and maintaining control in a classroom setting?

I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with assistance.
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. 
10.

What experience do you have researching best practices and scientific data to make recommendations for programs or interventions for specific audiences?

I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with assistance.
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. 

11.

Please check all experience you have working with news media or being interviewed.

I have developed press releases or other health promotion materials to be disseminated to news outlets.
I have given an interview on a radio station.
I have given an interview on a television station.
I have been a spokesperson for an event.
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.