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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 possess a current license as a Respiratory Care Practitioner from the Maryland Board of Physicians?

Yes No

If you answered "yes", please provide your license number and expiration date below.  You may also submit a copy of your license or license verification with your application.


Describe your experience as a Respiratory Care Practitioner.  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 this type of experience, please indicate N/A in the box below.


Do you possess a Bachelor's degree in Chemical, Physical, Biological or Clinical Laboratory Science? If so, please indicate the field in which your degree is in the text box below. Also, clearly indicate this information on your application.

Describe your experience providing patient care that meets regulatory guidelines set by the Joint Commission, Office of Health Care Quality, and the Commission on Accreditation of Rehabilitation Facilities.
This experience should be included on your application. If you do not possess this type of experience, please put N/A in the text box.


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