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#17-002820-0003
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 in nursing, social work, psychology, education, counseling or a related field?

Yes No
2.

Describe your experience with professional work in health or medical services in areas, other than Mental Health, Developmental Disabilities or Addictions. 

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.

3.

Do you have at least 2 years of STI/HIV disease intervention field experience?

Yes No
4.

If you answered "yes" to the previous question, please describe your STI/HIV disease intervention field experience in the space below.

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.

5.

Describe your experience with the Patient Reporting Investigating Surveillance Manager (PRISM) data system.  Include name of employer, job title, dates of employment, and hours worked per week for each relevant position.  If you do not have this experience, put N/A in the box below.


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