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#25-004216-0001
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 OR the date you will be sitting for the exam. Not providing this information may result in disqualification.

3.

Describe your experience with case management of patients with active tuberculosis and latent tuberculosis infection.

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.

4.

Describe your experience making home visits utilizing the appropriate personal protective equipment.

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.

Describe your experience with electronic medical records and data entry software.

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.

Bilingual applicants are encouraged to apply.

Are you bilingual in English and Spanish? You must be fluent in English and Spanish, meaning that you must be able to speak, read, write, and understand both Spanish and English.  

Yes No

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