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#17-002071-0005
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.

If yes, please list the required coursework (18 credit hours in Public Health Education, Community Health Education, Health Science or related behavioral science) in the space below using the following format.  You must also attach a copy of your official or unofficial transcripts to your application:

Example:  Course Number   Title                                                 Credits Earned

                     HEA  317          Community Health Interventions                3.0 

* This information will be verified upon employment

 

 

 
4.

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.

5.

Describe your experience in preparing and monitoring grant applications.

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 with tobacco prevention and cessation.

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 in public speaking.  Include name of employer, job title, dates worked, and hours worked per week.  If you do not possess this experience, put N/A in the box below.  


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