Social Services Coordinator (0808001)
Social Services Coordinator (1009014)
Applicant Name: Date:
SUPPLEMENTAL QUESTIONNAIRE
Supplemental questions are used to assist us in the evaluation of your application. By answering these questions, you help to reduce the amount of interpretation involved. Please complete the questionnaire and attach to a completed application.
1a. Select one of the options below that best describes your education and experience.
I have Bachelor’s degree, or higher, in: Social Work, Health Education, Health Care Administration, Special Education (Disabilities), or other health orientated program (excluding PE, Sports Medicine, etc). (Go to 1b)
I have 4 years social medical experience in an acute medical setting (e.g., hospital discharge planner, hospital social worker, etc). (Go to 1b)
I have an equivalent amount of education and experience to equal 4 years.
(Go to 1b)
I speak Spanish and/or bilingual.
(Go to 1b)
1b. Please provide the following information:
Degree Type: Hours to Date or Date Completed:
Place and dates where you obtained experience in social medical experience in an acute medical setting:
A)
B)
C)
2. Please indicate whether you have the following experience and list the position(s) where you obtained the experience.
Check all that apply and indicate where you obtained the experience
Advanced Education
Degree: Date Completed:
Social medical experience in an acute medical setting
Place and dates where you obtained the experience:
Medicaid experience
Place and dates where you obtained the experience:
Case management/utilization review experience
Place and dates where you obtained the experience:
Experience with persons who are Aged, Blind or Disabled
Place and dates where you obtained the experience:
Bilingual/other languages
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