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#17-001568-0002
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.

Are you a Certified Professional Alcohol and Drug Counselor or a Licensed Clinical Alcohol and Drug Counselor?  (If yes, please submit a copy of your certification or licensure by the closing date.  You can upload documentation with the application or send it directly to the DJS Human Resources Office.)

Yes No
2.

Do you have experience providing behavioral/mental health treatment to adolescents/at-risk juveniles in a secure juvenile setting or facility? If you have this experience provide the name of the employer and the dates of employment when you performed this work and the hours per week you performed this work. If you do not have this experience, enter N/A

3.

Do you have experience supervising behavioral/mental health professionals?

Yes No
4.

If you checked Yes to question #3, please be specific in fully describing this experience in the box below.  Include employer(s) and date(s) of employment.  This information must also be included in your application in order to receive credit.  If you do not have this experience, enter N/A. 


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