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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.**



Do you currently possess a license as a Certified Social Worker (LCSW) or Certified Social Worker, Clinical (LCSW-C) by the Maryland State Board of Social Work Examiners?

Yes No

If you answered Yes to the previous question, please provide the license number and expiration date in the box below.  A copy of your current license or license verification should also accompany your application.


Please indicate the date that you earned your Master's degree in Social Work in the space below (i.e., May 2010). If you do not have a Master's degree in Social Work, put N/A in the space below.


Describe your professional work experience rendering clinical social work services in a health care or treatment setting subsequent to the receipt of an approved Master's degree in Social Work from an accredited college or university.

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.


Please select the facilities where you are interested in working (you may select multiple locations). When completing your application, please be sure to select the counties associated with the facilities for which you have an interest in order to be considered:

Clifton T. Perkins Hospital Center, Jessup MD (Howard County)
Eastern Shore Hospital Center, Cambridge MD (Dorchester County)
Potomac Center/SETT, Hagerstown MD (Washington County)
RICA Baltimore, Baltimore MD (Baltimore City)
RICA John L. Gildner, Rockville MD (Montgomery County)
Springfield Hospital Center, Sykesville MD (Carroll County)
Spring Grove Hospital Center, Catonsville MD (Baltimore County)
Thomas B. Finan Center, Cumberland MD (Allegany County)

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