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#17-000520-0007
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 bachelor's degree from an accredited college or university in business, communications, or a mathematics related major?  If so, please indicate field of study in the box below.  If no, please write N/A.

2.

Describe your experience in health facility surveying and inspection of health care institutions. 

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 professional work experience in a health care setting or regulatory agency.

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 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
5.

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


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