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#18-004216-0070
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

Describe your experience providing clinical case management services to persons diagnosed with HIV+ or AIDS.

2

Describe your experience working with infectious diseases.

This experience should be included on your application. If you do not possess this type of experience, please put N/A in the text box.

3

Please describe your experience in community outreach, including dates of employment and employers. If you do not have this experience, enter N/A.

4

Do you possess a current license as a Registered Nurse from the Maryland State Board of Nursing, or a license recognized by the Multi-State Compact agreement OR will you be sitting for the licensing exam within the next 90 days?

Yes No
 

If you answered Yes to the above question, please provide your license number and expiration date in the space below.  If you do not possess a certificate of eligibility, please indicate N/A in the text box below.


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