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#17-004263-0005
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.

Are you Board Certified in Infection Control (CIC)? If you respond "YES" to this question, please attach a copy of your certification to your application.

Yes No
2.

Please describe your work experience with infection prevention and control methods in acute and/or long term care.  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.

Please describe your work experience in nursing practices and infectious diseases.  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.

Please describe your experience working with infection control practitioners and management level personnel in a health care setting.  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.

5.

Please describe your experience providing health education/training.  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 experience as a Registered Nurse in an administrative, supervisory, consultative or teaching 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.

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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