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Human Capital Management
#170921-Z12C-01


Supplemental Questionnaire

Last Name First Name
 

 

OK Department of Human Services (DHS) requires that the following questions be answered before continuing with the application.


 

Do you have legal status to work in the United States?

Yes No
 

Have you had a protective order entered against you pursuant to the Oklahoma
Protection from Domestic Abuse Act or a similar statute of another state? 

If yes, provide the name of the court and court number in the text area:

If no, please enter No in the text area:            

 

DHS policy does not allow some family members to be employed within the same supervisory group or unit. Please list the names of all of your relatives now employed by DHS:

If no, please enter No in the text area:

 

Have you ever been terminated or resigned from employment in lieu of being terminated?  
If yes, explain circumstances:      

If no, please enter No in the text area:

 
Do you have any of the following?
two (2) years of experience working with children or adults in a treatment facility for disabled individuals
two (2) years of experience working with children or adults in a residential or school setting
none of the above

 

ATTENTION!

 Please verify that you meet the education and experience requirements listed in the job bulletin before completing the following supplemental questionnaire. The questions below will be used for scoring purposes, in lieu of a written exam.


1.

What experience do you have performing routine duties in the care, custody education, and treatment of clients?

I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I am familiar with this task or have received some training on it.
I have no experience with this task.
 

Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 

2.

What experience do you have performing routine duties in the care, custody, education, and treatment of youth or children residing in an institution, shelter, group home, or school?

Performing this task was a major part of my job.
Performing this task was a major part of my job with partial supervision.
Performing this task was a minor part of my job duties.
Performing this task was not part of my job duties.
 

Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 

3.

What experience do you have providing guidance and counseling to clients to help find solutions to their personal problems?

I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I am familiar with this task or have received some training on it.
I have no experience with this task.
 
Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 
4.

What experience do you have serving on a treatment team to review a resident's progress, treatment and educational plans?

Performing this task was a major part of my job.
Performing this task was a major part of my job with partial supervision.
Performing this task was a minor part of my job duties.
Performing this task was not part of my job duties.
 

Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 

5.

What experience do you have educating clients in life skills?

I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I am familiar with this task or have received some training on it.
I have no experience with this task.
 

Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 

6.

What experience do you have ensuring the cleanliness of facilities through inspections, reports and adherence to safety standards?

Performing this task was a major part of my job.
Performing this task was a major part of my job with partial supervision.
Performing this task was a minor part of my job duties.
Performing this task was not part of my job duties.
 
Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 
7.

What experience do you have lifting individuals to and from wheelchairs, floor mats, baths, or beds?

I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I am familiar with this task or have received some training on it.
I have no experience with this task.
 
Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 
8.

What experience do you have supervising residents to and from facilities for activities and off-campus appointments?

I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I am familiar with this task or have received some training on it.
I have no experience with this task.
 

Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 

9.

Please check all of the following certifications you have obtained.  Check all that apply.

Certified Medication Aide (CMA)
Medication Administration Technician (MAT)
Cardio Pulmonary Resuscitation (CPR)
First-Aid
Behavior Intervention Technique
I have none of the certifications listed above.
 

Please list the employer and job title where you gained your certification as indicated in the response above.  If you indicated "no certification", then please type N/A below.