**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 OR the date you will be sitting for the exam. Not providing this information may result in disqualification.
3.
Do you possess Wound Care certification? If YES, please attach certificate to your application.
Yes
No
4.
Describe your experience providing wound care.
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 utilizing a trauma informed approach to establish a relationship with participants and experience with harm reduction services, including providing care with a non-judgmental approach.
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 serving individuals affected by substance use and mental health disorders as well as experience with community resources to provide referrals to 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.
7.
Describe your experience providing infectious disease screening, testing and linkage to care, especially HIV and Hepatitis A, B and C.
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.
8.
Describe your knowledge of and/or experience with sexually transmitted infections and your ability to provide reproductive health education.
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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