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#23-004294-0001
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 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.

Describe your nursing experience in the supervisory, consultative, teaching or administrative capacity.  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. 

4.

Please describe your knowledge of and/or experience with regulations pertaining to the long term care population. This experience should be included on your application, including hours and dates worked. If you do not possess this type of experience, please put N/A in the text box.

5.

Please describe your experience in completing investigations as they relate to patient care issues. This experience should be included on your application, including hours and dates worked. If you do not possess this type of experience, please put N/A in the text box.

6.

Please describe your administrative experience in a hospital long term care or government setting. This experience should be included on your application, including hours and dates worked. If you do not possess this type of experience, please put N/A in the text box.


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