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#17-004244-0002
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 in Nursing?  (If Yes, indicate this clearly on your application.)

Yes No
2.

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
3.

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

4.

Do you have experience in one or more of the following types of programs:  Home Health Agencies, Hospice Programs, End Stage Renal Dialysis Centers, Ambulatory Surgical Centers, Comprehensive Outpatient Rehabilitation Facilities, or Outpatient Physical Therapy?

Yes No
5.

If you answered "yes" to the previous question, please describe your experience working in these programs.  Be sure to indicate the type of program(s) that you worked in, name of employer, job title, and hours worked per week for each relevant position.  This information must also be reflected in your application.  Do not copy and paste from your resume.  If you do not have this experience, put N/A in the box below. 

6.

This eligible list may be used for various vacancies within the Office of Health Care Quality.  Please check the units for which you are interested in working.  The description for each unit can be found on the job announcement:

Ambulatory Care Unit
Assisted Living and Adult Medical Day Care Unit
Behavioral and Allied Health Unit
Developmental Disabilities Unit
Hospital and HMO Unit
Long Term Care (Nursing Home) Unit

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