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#17-004218-0013
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.***


1.

Describe your work experience with Emergency Preparedness (i.e., general nursing, public education, public health response team, communicable disease). 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.

2.

Describe your work experience with program coordination. 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.

3.

Describe your experience as a Community Health Nurse. 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.

6.

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.

Do you have a Bachelor's degree in Nursing?  (If Yes, indicate this clearly on your application.)

Yes No
5.

Do you possess a Master’s degree in Nursing or a related field from an accredited college or university?

Yes No
7.

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
8.

Please provide your license number and expiration date in the box below.


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