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#17-002071-0004
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 in Public Health Education, Community Health Education or Health Science?

Yes No
2.

If you do not have a Bachelor's degree in Public Health Education, Community Health Education, or Health Science, do you have a minimum of 18 credits hours in Public Health Education, Community Health Education, Health Science, or a related behavioral science? 

If you answered "yes" to this question, a copy of your transcripts (official or unofficial) must be submitted with your application to receive credit. 

Yes No
3.

Do you possess a Master's degree in Public Health, Community Health Education or Health Science?

Yes No
4.

Do you possess a Doctorate in Public Health, Community Health Education, Health Science or Public Health Policy?

Yes No
5.

Describe your experience planning, developing, implementing and promoting health education projects. 

Include name of employer, job title, dates employed, and hours worked per week for each position that demonstrates this experience.  If you do not have this experience, put N/A in the box below.

6.

Describe your work experience with chronic disease program coordination.  This information should also be reflected in your application.  If you do not possess this type of experience, indicate N/A in the text box below.


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