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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.***


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

If yes, please provide your license number, expiration date and state (if it is a compact state). Not providing this information may result in disqualification.  If you do not possess this license please write N/A.


Describe your experience with clinical and case management services pertaining to communicable diseases.

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.  You may include related internship or volunteer experience.  If you do not have this experience, put N/A in the box below.

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