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#19-004220-0006
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 with performance management systems.

This experience must also be included on your application (please include name of employer, job title, dates of employment and hours worked per week). If you do not possess this type of experience, please indicate N/A.

2

Describe your professional work experience within the public health field.

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.

3

Describe your experience implementing population-based health programs.

This experience must also be included on your application (please include name of employer, job title, dates of employment and hours worked per week). If you do not possess this type of experience, please indicate 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?

Yes No

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