**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.
Are you currently licensed to practice medicine by the Maryland Board of Physicians? (If Yes, please submit a copy of your license or license verification with your application.)
Yes
No
2.
If you answered Yes to the above question, please provide your license number and expiration date in the space below. If you do not possess a certificate of eligibility, please indicate N/A in the text box below.
3.
Do you posses a current Board Certification?
Yes
No
4.
Please provide the date when you received your Board Certification. Also provide your area of speciality. Type "NA" in the field below, if this does not apply to you.
5.
Describe your professional experience one or more areas of compliance, licensing and/or inspection; legislative, legal, regulatory; or quality of care in residential care settings, such as nursing homes/long term care, assisted living, or group homes.
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.
6.
Describe your experience at the supervisory or managerial level.
Please include name of employer, job title, dates of employment, and hours worked per week. If you do not possess experience in this area, put N/A in the box below.
7.
Describe your experience planning, developing or implementing plans of correction to ensure health care quality.
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.
Department of Budget and Management