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#18-004219-0003
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.

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.

3.

Describe your experience as a community health nurse. 

Include name of employer, job title, dates employed, and hours worked per week for each relevant position.  If you do not have this experience, put N/A in the box below.

4.

Describe your experience in an administrative, supervisory, consultative, or teaching capacity as a registered nurse. 

Include name of employer, job title, dates employed, and hours worked per week for each relevant position.  If you do not have this experience, put N/A in the box below.

5.

Describe your experience with providing Adult Evaluation and Review Services and/or Nurse Monitoring Services.

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 with the Long Term Services and Supports Maryland web based portal.

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.


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