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#1119-RM0226-SR
Supplemental Questionnaire

Last Name
First Name

 

Please provide responses to the following questions.  This supplemental questionnaire is an extension of your employment application and will be reviewed to thoroughly assess your qualifications.  Resumes are not accepted in lieu of completing this questionnaire.

When responding to questions relating to your work experience, please provide a detailed description that includes the name of your employer, dates of employment (beginning and end dates), job title, number of hours worked per week, and indicate if experience was paid or unpaid.


1.

Did you graduate from an accredited four year college or university with a major in public or business administration, accounting, finance, economics, social or behavioral science, or a closely related field?

Yes No
 

If yes, please provide the name of the four year college or university, degree earned and the field of study.

2.

Do you possess three years of progressively responsible managerial, fiscal, personnel or governmental administrative and/or analytical work?

Yes No
 

If yes, please provide an overview of your progressively responsible managerial, fiscal, personnel or governmental administrative and/or analytical work. 

3.

Did at least one year of the aforementioned experience occur while working for a Federally Qualified Health Center (FQHC) performing at least at a journey level analyst capacity?

Yes No
 

Describe the duties performed for the FQHC organization.

4.

Do you have any experience appraising operating results that have bearing on the fiscal soundness and operating effectiveness of an FQHC organization (or FQHC-LAL)? If yes, please describe below.