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#19-003331-0001
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 Dietitian/Nutritionist from the Maryland State Board of Dietetic Practice?

Yes No
2.

If you answered "yes", please provide your license number and expiration date below.  You may also submit a copy of your license or license verification with your application.

3.

Describe your experience providing professional nutrition or dietetic services.

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

4.

Please describe in the box below your professional experience with the Maryland WIC Program.  Please include name of employer(s), job title(s), dates of employment, and hours worked.  If this does not applly to you, enter N/A in the box below.

5.

Describe your experience providing nutrition counseling to high-risk WIC participants.

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 your experience determining eligibility for the WIC program.

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.

7.

Describe your experience developing, implementing and evaluating educational nutrition materials.

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.


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