Official SealPersonnel Commission


#19-5258-001
Supplemental Questionnaire

Last Name
First Name

 

INFORMATION AND INSTRUCTIONS:  The information you provide on the standard application form and on this supplemental questionnaire will be used to evaluate your qualifications for this position.  You are to provide explicit, but concise, statements in response to each section.  It is your responsibility to assure that information you deem important to your candidacy is included in your responses.  Your responses to this questionnaire must be supported by the information on your application to be considered.  Resumes or referral to a resume in lieu of a response will not be accepted.

The information you provide is subject to verification. Please follow all instructions carefully. Errors or omissions may affect your rating or consideration for employment.


1

Have you successfully completed a patient care simulator training program?

Yes No
2

If you've responded "Yes" to the question above, then please list below the institution where the training program was completed, including the dates attended and the month and year when the program was completed. Place "N/A" if not applicable.

3

Do you have full-time, paid experience in the programming, operation, and maintenance of simulation based medical learning systems?

Yes No
4

If you've responded "Yes" to the question above, then please list below the name of the agency/company where experience was gained including your job title, employment dates, and hours worked (example: ABC Hospital, Simulation Technician, 10/2015-01/2017, 40 hours per week). Place "N/A" if not applicable.

5

Do you possess current valid certification in one or more of the following? (check all that apply)

Certified Nursing Aide (CNA)
Emergency Medical Technician (EMT)
Heath related field not listed
6

If you checked "Health related field not listed," please identify below the name of the certification, the institution where it was obtained, and the date it was awarded. Place "N/A" if not applicable.