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#18-004609-0008
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

This position requires that you possess a Board Certification.  Please indicate the field in which you have your Board Certification.

3

Describe your medical practice experience. 

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. 

4

Please describe your supervisory experience.  Include employer name(s), job title(s), dates of employment, and titles of those you supervised.  If you do not possess this experience, enter N/A.

5

Describe your knowledge and/or experience in infectious disease epidemiology.

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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