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#19-004217-0001
Supplemental Questionnaire

Last Name
First Name
1

Do you possess a Master's degree in Psychiatric or Mental Health Nursing or a Mental Health field from an accredited college or university? If YES, please upload copy of transcript to application (unofficial versions acceptable).
Yes No
2

Do you posses certification as a Psychiatric or Mental Health Nursing Specialist from the American Nurse Association or other nursing bodies approved by the Maryland State Board of Examiners of Nurses? If YES, please upload copy of the certification to application.
Yes No
3

Describe your experience as a RN in the field of mental health.

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

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
5

If you indicated YES to the above question, please include your license number and expiration date in the text box below.

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