***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 certificate as a Nurse Practitioner or as a Nurse Midwife from the Maryland State Board of Nursing?
Yes
No
2.
Do you currently possess a current Nurse Practitioner certification (Pediatrics or Family)? If so, please identify which certification you possess. If you do not possess a certification, type N/A.
3.
Are you CPR/AED certified?
Yes
No
4.
Please explain your experience as a board-certified nurse practitioner in Pediatrics or Family? Include the employer’s name, employment dates, and hours worked per week. If no experience, type N/A.
5.
Please explain your clinical supervision or management experience. Please describe your experience. Include the employer’s name, employment dates, and hours worked per week. If no experience, type N/A.
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