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#17-004609-0007
Supplemental Questionnaire

Last Name
First Name

 

Please note that your answer on the supplemental questionnaire must correspond to the information that is provided on your resume to receive credit.


1

Are you currently licensed to practice medicine by the Maryland Board of Physicians?  (If Yes, please submit a copy of your license or license verification with your application.)

Yes No
2
Are you Board Certified in Psychiatry? Please submit a copy of your license with your application.
Yes No
3

Are you Board Certified in Forensic Psychiatry?  Please submit a copy of your certification with your application.

Yes No
4

Describe your experience in a medical practice working with patients with mental illness and substance use disorders.

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.

5

Describe your experience working with patients with mental illness and substance use disorders connected to the legal/criminal justice system.

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 at a supervisory or administrative level in a health care organization or system.

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.

7

Describe your knowledge about the public sector Maryland Behavioral Health Care system.

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.


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