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#17-005213-0002
Supplemental Questionnaire

Last Name
First Name
1

Please indicate your American Sign Language skill level

a. Polite (able to greet and exchange pleasantries; indicate or understand an emergency)
b. Literate (understands a conversation and can respond)
c. Fluent (is your native language or can converse in the language as if it was your native language.)
d. Do not speak sign language.
2

Do you have experience working with young children in a school or hospital setting?  If yes, please explain.  If no, write “N/A.”

3

Do you currently possess a valid Registered Nurse license from the Maryland State Board of Nursing?

Yes No

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