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#22-004686-0002
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.**

 


1.

Do you have a current Certified Nursing Assistant license in Maryland?

Yes No
2.

If you currently possess a current Certified Nursing Assistant license, then type your CNA license number in the field below.  Please note that you are required to upload a copy of your license with your application.

If you do not have a CNA license, then type "N/A" in the field below.

3.

Do you possess 60 credits from an accredited college or university with at least 15 credits in health services, human services, education or the behavioral sciences?  Please note, you must submit your transcript(s) with the application.

Yes No
4.

Explain your experience providing residential services in a developmental disability or similar behavior modification setting.

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.

5.

Describe your experience supervising direct care staff.

This experience must also be included on your application. Please be sure to include name of employer, job title, dates of employment and hours worked per week. If you do not possess experience in this area, indicate N/A.

6.

Describe your experience working with clients who are intellectually disabled. 

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.

7.

Describe your experience with a forensic population.

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.


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