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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.***


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

If you responded Yes to question 1, please provide your license number and full expiration date in the box below.  If your license is from a compact state, please provide a copy of your license or license verification.  Enter N/A if this question does not apply to you.


Describe your experience providing nursing support to a communicable disease program's clinical and case management services.

Include name of employer, job title, dates employed, and hours worked per week for each relevant position.  If you do not have this experience, put N/A in the box below. 

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