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#22-004216-0037
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 OR the date you will be sitting for the exam. Not providing this information may result in disqualification.

3.

Describe your experience in infectious disease control, surveillance and treatment.

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.

 

4.

Describe your experience with prophylaxis services.

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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