**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 Registered Nurse from the Maryland State Board of Nursing, or a license recognized by the Multi-State Compact agreement?
Yes
No
2.
Please provide your license number and expiration date in the box below.
3.
Please describe your experience as a Registered Nurse in an administrative, supervisory, consultative or teaching capacity.
Please include name of employer, job title, dates of employment, and hours worked per week. If you do not possess experience in this area, put N/A in the box below.
4.
Describe your RN experience as a delegated nurse in DDA services (within Maryland).
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.
5.
Describe your experience with community resources. 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 knowledge of and/experience with COMAR 10.27.11.
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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