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#20-004261-0001
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 Master's degree in Nursing or a health-related field?

Yes No
2

What field of study is your master's degree in?

3

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
4

Please provide your license number and expiration date in the box below.

5

Describe your experience in an administrative, supervisory, consultative, or teaching capacity as a registered nurse. 

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

6

Describe your experience in the field of cancer screening, preferably in providing clinical guidance and/or monitoring clinical quality measures.

Please include name of employer, job title, dates of employment, and hours worked per week, this information must also be reflected in your application.  If you do not possess experience in this area, put N/A in the box below.

7

Describe your experience monitoring program performance standards through data review, data error reports, data tables, critical failure points and other reports.

Please include name of employer, job title, dates of employment, and hours worked per week, this information must also be reflected in your application.  If you do not possess experience in this area, put N/A in the box below.


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