Department of Budget and Management

**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.**

Describe your experience in health facility surveying and inspection of health care institutions. 

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.

Describe your professional work experience in a health care setting or regulatory agency.

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.

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?

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

Describe your professional work experience as a Coordinator.

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.

Describe your experience reviewing and documenting deficient practices.

With your description, include name of employer, job title, dates of employment, and hours worked per week for each relevant position.  This experience must also be reflected in the "Work Experience" section of your application.  If you do not have this experience, put N/A in the box below.

Describe your experience with conducting surveys.

With your description, include name of employer, job title, dates of employment, and hours worked per week for each relevant position.  This experience must also be reflected in the "Work Experience" section of your application.  If you do not have this experience, put N/A in the box below.

Describe your knowledge of and/or experience with determining a facility's compliance with local, State and federal regulations in an assisted living and/or adult medical daycare setting.

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.