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Supplemental Questionnaire

Last Name
First Name

This position requires possession of certification in Advanced Cardiac Life Support (ACLS)

Do you possess a current certification in Advanced Cardiac Life Support (ACLS)?  If yes, identify the date the certification was issued and when it expires.

Note: You must provide a copy of the certificate to be considered for this position.

Please describe your administrative or management experience in an emergency medical or trauma field. Please include your scope of responsibility and your role in the organization.

Describe your knowledge of and experience with registry programs for trauma, cardiac, and stroke.

Describe your education related to this position. Include degrees, courses of study and certificates.

Describe your experience writing project reports, documenting investigations, or preparing research findings.

Describe your experience establishing, implementing and monitoring professional or clinical standards.