Official SealHuman Resource Services Department


#17-5141-01
Supplemental Questionnaire

Last Name
First Name
 

Applicants for this position are required to submit responses to the following supplemental questions.  Your completed responses to the supplemental questionnaire will be evaluated to determine your qualifications and must be completed properly in order to be given full consideration for the next phase in the selection process. Additionally, your responses will also be evaluated and used in the selection process in order to identify the best qualified applicants.

Responses should be thorough and specific.  A lack of detail and explanation in the supplemental questions and in your application may result in failure or disqualification for this position.  Clarity of expression, content, experience, grammar, spelling and the ability to follow instructions will be considered in the evaluation process.  A resume will not be accepted as a substitute for properly completed responses.

Information provided in your responses to the supplemental questionnaire regarding your employment experiences must also be detailed in the Work Experience section of the application for this recruitment.  Please be sure to list all employers and required information, on your application, especially if you are referencing those employers in your responses to the supplemental questions.

By selecting yes below, you certify your understanding that all applicants must submit a complete application and complete responses to the supplemental questions in order to be considered for this recruitment. Do you understand the above statement?

Yes No
1.
Do you possess a valid license to practice medicine in the State of California? If yes please list your license number, If "No" please enter N/A below.
2.

Please describe your experience working in communicable disease control and prevention programs implementing prevention, control, and follow-up of legally mandated reportable diseases in a public health or health care setting. In your response, please include your specific role, as well as the size and jurisdiction of the agency or organization. 

3.

Please describe your experience interpreting and implementing health officer authorities and legal statutes (eg isolation or quarantine orders, mandated reporting) and implementation relevant to communicable disease control. 

4.

Please describe your experience leading or participating in a multidisciplinary collaborative effort to develop strategies or policies to address complex problems related to medical screening, prevention, treatment, or public health policies or interventions for TB, HIV/AIDS, STDs, or other communicable disease(s).  In your response, please include your role, the types of team members and partners involved, and what were the specific outcomes?

5.

Previous experience involving lead or supervisory responsibility may suitably prepare someone to be successful in this position.  Describe your experience providing lead direction and/or supervision to a multi-disciplinary team. In your response, list the approximate total number of staff, direct reports, and types of employees supervised (eg public health nurses, disease control investigators, outreach workers, epidemiologists, clerical staff, etc.) as well as the employer where the experience was gained.

6.

In compliance with the Administrative Simplification provision of the Health Insurance and Accountability Act of 1996 (HIPAA), employees in this classification are required to possess a National Provider Identifier (NPI) number prior to their first day on the job. Additionally, in compliance with Medicare regulations, employees in this classification are required to complete the "Medicare Enrollment Process for Physicians and Non-Physician Practitioners" through the Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services, prior to their first day on the job. Active enrollment in Medicare is a condition of employment. Failure to attain or maintain active enrollment will result in termination.

By selecting yes below, I understand that I will be required to meet these standards prior to my first day on the job.

 

Yes No
 

The supplemental questions were designed to elicit your experience as it relates to the current recruitment in order to identify the best qualified candidates for this position. Only the best and most suitably qualified candidates will be invited to participate in the oral interviews.

By selecting yes below, you certify your understanding that all applicants who meet minimum qualifications are not guaranteed to move forward in the process. Do you understand the above statement?

Yes No

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