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#17-002589-0011
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.***


1.

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

Yes No
2.

Do you have a graduate degree in Public Health, Health Science, Hospital/Health Care Administration, or a related field with research or statistical coursework?

Yes No
3.

If yes, please specify your degree and the field of study in which you earned your degree below.

4.

Please describe your years of experience in administrative staff or professional work, including dates and hours worked. (This experience must also be listed on your application).

5.

Describe your experience involving one or more of the following:  the supervision of other employees, overseeing and coordinating the general operations of a unit, applying rules and regulations, or exercising responsibility for the development of policies or procedures.  

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. 

6.

Describe your experience performing health research and/or evaluation work, particularly in the fields of behavioral health or substance use epidemiology.

With your description, include name of employer, job title, dates of employment, and hours worked per week for each relevant position.  This experience must also be reflected in the "Work Experience" section of your application.  If you do not have this experience, put N/A in the box below.

7.

Describe your experience evaluating, analyzing, researching and developing health care services, policies, and programs.

Please include name of employer, job title, dates of employment, and hours worked per week for each relevant position.  If you do not possess experience in this area, put N/A in the box below. 


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