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#18-005478-0027
Supplemental Questionnaire

Last Name
First Name

 

Please note that your answer on the supplemental questionnaire must correspond to the information that is provided on your resume to receive credit.


1

Do you have a current Maryland Pharmacist license?

Yes No
2

If you answered Yes to the previous question, please provide the license number and expiration date in the box below.  A copy of your current license or license verification should also accompany your application.

3

Describe your experience as a registered pharmacist.

Please include name of employer, job title, dates of employment, and hours worked per week for each relevant position.  This experience must be reflected on your application.  If you do not have experience in this area, put N/A in the box below.

4

Describe your clinical pharmacy experience as a Registered Pharmacist.

Please include name of employer, job title, dates of employment, and hours worked per week for each relevant position.  This experience must be reflected on your application.  If you do not have experience in this area, put N/A in the box below.

5

Describe your experience in pharmacy claims processing.

Please include name of employer, job title, dates of employment, and hours worked per week for each relevant position.  This experience must be reflected in your application.  If you not have experience in this area, put N/A in the box below.

6

Please describe your experience with Medication Therapy Management (MTM), and any specific disease management programs with significant medication component which you have been involved with.

7

Do you have any Board Certifications, Disease State Certifications, or completed any Accredited Pharmacy Residency programs? Please elaborate.

8

Please describe your experience and/or training in statistics or computer database analysis, as it relates to drug utilization, pharmacy claims data, or pharmacy reimbursement/pricing methodologies.


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