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#19-004262-0002
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.***


1

Do you possess a Master's degree in Public Health or Master's of Science in Public Health (MPH/MSPH)? If you respond YES, please upload copy of transcript to application.

Yes No
2

Describe your school health or public health nursing experience.

This experience must also be included on your application (please include name of employer, job title, dates of employment and hours worked per week). If you do not possess this type of experience, please indicate N/A.

3

Describe your policy development and implementation experience.

This experience must also be included on your application (please include name of employer, job title, dates of employment and hours worked per week). If you do not possess this type of experience, please indicate N/A.

4

Describe your experience with clinical nursing protocols and procedure development.

This experience must also be included on your application (please include name of employer, job title, dates of employment and hours worked per week). If you do not possess this type of experience, please indicate N/A.

5

Describe your program monitoring and evaluation experience.

This experience must also be included on your application (please include name of employer, job title, dates of employment and hours worked per week). If you do not possess this type of experience, please indicate N/A.

6

Describe in the box below your managerial experience.  Include employer name(s), job title(s), dates of employment and explain your managerial duties.  (If you do not possess this experience, enter N/A)

7

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
8

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.


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