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#19-004216-0093
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 current license as a Registered Nurse from the Maryland State Board of Nursing, or a license recognized by the Multi-State Compact agreement?

Yes No
2

Please provide your license number and expiration date in the box below.

3

Describe in 1-3 paragraph(s), your recent experience working in a health care setting as an Registered Nurse.

Do not copy and paste from your resume. 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

Describe in 1-3 paragraph(s), your experience working with and educating the community about illness, disease prevention and control.  

 Do not copy and paste from your resume. 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 in 1-3 paragraph(s), your knowledge/experience using electronic databases for disease reporting.

Do not copy and paste from your resume. 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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