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#19-004606-0008
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.

Do you possess a degree in medicine from an accredited college or university?
Yes No
2.

Are you certified by an American Medical Association Specialty Board in an area of medical specialization? Please identify area of medical specialization on application or attach pertinent information to application.
Yes No
3.

Do you possess a certificate in Thoracic Surgery OR Preventive Medicine from the American Medical Association Specialty Board? If YES, please upload copy of certificate to application.
Yes No
4.

Are you licensed by the Maryland Board of Physicians to practice medicine under Maryland State Law?  If so, please attach copy of license to application.
Yes No
5.

Describe your experience working with infectious diseases, especially working with tuberculosis.

With your description, include name of employer, job title, dates of employment, and hours worked per week for each relevant position.  This experience must also be reflected in the "Work Experience" section of your application.  If you do not have this experience, put N/A in the box below.

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