**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 have experience providing nursing care to patients who are receiving either hemodialysis or peritoneal dialysis?
Yes
No
If yes, please explain. Include job duties, place of employment, dates and hours worked per week. If you do not possess this experience put N/A in the box below.
2.
Do you have experience managing, coordinating and evaluating nursing care in a hospital based outpatient dialysis center?
Yes
No
If yes, please explain. Include job duties, place of employment, dates and hours worked per week. If you do not possess this experience put N/A in the box below.
3.
Do you have experience supervising nursing care delivered to patients by dialysis staff?
Yes
No
If yes, please explain. Include job duties, place of employment, dates and hours worked per week. If you do not possess this experience 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.
Department of Budget and Management