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#19-004292-0003
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 currently possess a valid Registered Nurse license from the Maryland State Board of Nursing?

Yes No
2.

Please explain your experience as a Registered Nurse in a supervisory, administrative or consultative capacity. Please include the employer(s) names, dates of employment, job duties and hours worked per week. If you do not have this experience, please write N/A.

3.

Please explain your experience coordinating and supervising across multiple secure residential juvenile facilities/settings.  Please include the employer(s) names, dates of employment, job duties and hours worked per week. If you do not have this experience, please write N/A.


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