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#22-004288-0004
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.

Please indicate your American Sign Language skill level:

a. Polite (able to greet and exchange pleasantries; indicate or understand an emergency)
b. Literate (understands a conversation and can respond)
c. Fluent (is your native language or can converse in the language as if it was your native language.)
d. Do not speak sign language.
2.

Do you have experience working with young children in a school or hospital setting?  If yes, please explain.  If no, write “N/A.”

3.

Do you currently possess a valid Registered Nurse license from the Maryland State Board of Nursing?

Yes No

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