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Human Capital Management
#191008-Y10C-12


Supplemental Questionnaire

Last Name First Name
 
 
Do you have three years of experience in providing patient care?
Yes No

 
STOP! You have completed the required screening questions for this Job Family.  Please verify you meet the education and experience requirements listed in the job bulletin before completing the following supplemental questionnaire. The questions below will be used for scoring in lieu of a written exam.

1.
I have work experience taking vital signs.
I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I am familiar with this task or have received some training on it.
I have no experience with this task.
 

Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 

2.
What experience do you have observing patients?
I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I am familiar with this task or have recieved some training on it.
I have no experience with this task.
 

Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 

3.
I have work experience processing lab specimens.
I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I am familiar with this task or have received some training on it.
I have no experience with this task.
 
Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 
4.
What experience do you have charting patient information?
I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I am familiar with this task or have received some training on it.
I have no experience with this task.
 

Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 

5.
I have work experience handling and cleaning blood borne pathogens.
I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I am familiar with this task or have received some training on it.
I have no experience with this task.
 

Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 

6.
What experience do you have with medical terminology?
I have used medical terminology as a regular part of my job.
I have used medical terminology as a regular part of my job with some supervision.
I am familiar with medical terminology or have received some training on it.
I have no experience with medical terminology.
 
Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 
7.
What experience do you have ordering, receiving and storing supplies?
I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I am familiar with this task or have received some training on it.
I have no experience with this task.
 
Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 
8.
What experience do you have maintaining inventory?
I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I am familiar with this task or have received some training on it.
I have no experience with this task.
 

Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 

9.
What experience do you have reporting pertinent changes in a patient's condition?
I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I am familiar with this task or have received some trianing on it.
I have no experience with this task.
 
Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 
10.
What experience do you have in follow-up activities and tracking clients?
I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I am familiar with this task or have received some training on it.
I have no experience with this task.
 
Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 
11.
What experience do you have using a computer?
I have used the computer independently as a regular part of my job.
I have used the computer as a regular part of my job with some supervision.
I am familiar with computers or have received some training on them.
I have no experience with computers.
 
Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 
12.
What experience do you have being a team leader in a work environment?
I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I am familiar with this task or have received some training on it.
I have no experience with this task.
 
Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 
13.
What experience do you have directing the work of other employees in the medical field?
I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I am familiar with this task or have received some training on it.
I have no experience with this task.
 
Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 
14.
How many employees have you been in charge of directing at one time in the medical field?
More than 10.
6-10
1-5
0
 
Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below.