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#17-002924-0001
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. Applications that do not include a completed supplemental questionnaire will be considered incomplete and may be subject to disapproval.**

 


1.

Do you possess a Bachelor's degree from an accredited college or university with a major or a minimum of thirty (30) credits in one of the biological sciences?  If you respond YES to this question, please attach a copy of your transcript to the application.

Yes No
2.

Describe your experience in public health investigation work. 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.

Describe your experience with medical records abstraction, medical coding, and case management. 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.

4.

Describe your experience creating, updating and maintaining procedural manuals and materials. In your description, please include the types of procedural manuals/materials that were created and the name(s) of employer(s) and dates of employment.

If you do not possess this experience, please enter N/A.

5.

Describe your experience related to maternal and child health.


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