Department of Human Resources

CITY AND COUNTY OF SAN FRANCISCO

2467 DIAGNOSTIC IMAGING TECHNOLOGIST I

SUPPLEMENTAL QUESTIONNAIRE

The purpose of this Supplemental Questionnaire is to obtain information regarding your education, experience and/or training in relation to this classification. This Supplemental Questionnaire must be completed and submitted online with the application. Responses cannot be changed or edited after submission. Failure to provide complete responses to this Supplemental Questionnaire may result in rejection of the application.

This Supplemental Questionnaire consists of three sections. The first section will be used as a tool to screen applications for minimum qualification requirements. The second will be used to measure your knowledge, skills and/or abilities in job-related areas. The third sections will be used to determine if applicants possess creditable work experience under the Job Experience Credit (JEC) program.

By selecting "yes" below, you confirm that you understand that your qualifying education, experience and/or training MUST be included in the body of your application and in this Supplemental Questionnaire.

Select the options that most closely describe the certifications that you possess. Please note, if the education/certifications listed on your application do not support the selections that you make on these questions, your application will be rejected. Be sure to include all relevant certifications and education on your application. A resume will not substitute for a completed application. If you write “see resume” on the application or Supplemental Questionnaire, your application will be rejected.

Minimum Qualification #1

Minimum Qualification #2

Minimum Qualification #4

Minimum Qualification #5

Please list any additional certifications or education that you possess, beyond the certifications required for this classification as indicated in the minimum qualifications section of the announcement. If you do not posses any additional certifications or education please indicate "N/A" below.

INSTRUCTIONS: The purpose of this portion of the Supplemental Questionnaire is to determine your knowledge, skills and abilities in job-related areas that have been identified as critical for satisfactory performance in this classification. The information provided here must be consistent with the information on your application and is subject to verification.  Please note, if the experience listed on your application does not support the selections that you make on these questions, your application may be rejected. Be sure to include all relevant experience in the work history sections of the application. A resume will not substitute for a completed application. If you write “see resume” on the application, your application will be rejected.

For each of the following statements select the corresponding amount of fulltime firsthand experience you have performing the stated task(s). If you performed the stated task(s) as a part-time employee, please note that 1,000 hours of qualifying experience is equivalent to 6 months of fulltime experience. Additionally, experience gained in a classroom and/or as a trainee on-the-job does not constitute firsthand experience. Please also provide the information requested in the text box following each statement.

Performing general diagnostic imaging procedures using fixed or portable, general, digital or fluoroscopic diagnostic imaging equipment.

List the name of your Employer/Agency, your Supervisor, and his or her contact information along with the dates of employment where you gained the experience indicated above.

Also list your Position or Job Title at the time the task was performed and the number of months/years you performed the task.

(If you did not perform this function please type N/A in the box below.)

Positioning patients and selecting technical factors based on knowledge of radiologic science, specific equipment and patient assessment, including processing films.

List the name of your Employer/Agency, your Supervisor, and his or her contact information along with the dates of employment where you gained the experience indicated above.

Also list your Position or Job Title at the time the task was performed and the number of months/years you performed the task.

(If you did not perform this function please type N/A in the box below.)

Applying principles of radiation safety in compliance with federal, state, and departmental logs, in accordance with regulatory, hospital and departmental standards; This includes using appropriate filters, cones, protective clothing and devices to obtain high-quality images with radiation exposure levels as low as reasonably achievable to patients, others and self and wearing and exchanging radiation monitoring devices.

List the name of your Employer/Agency, your Supervisor, and his or her contact information along with the dates of employment where you gained the experience indicated above.

Also list your Position or Job Title at the time the task was performed and the number of months/years you performed the task.

(If you did not perform this function please type N/A in the box below.)

Assessing general patient condition, including stability, pain, safety and, as necessary, taking action consistent with standards; monitors medical equipment and promptly adjusts or reports problems; observes and documents patient physical and procedural restraints.

List the name of your Employer/Agency, your Supervisor, and his or her contact information along with the dates of employment where you gained the experience indicated above.

Also list your Position or Job Title at the time the task was performed and the number of months/years you performed the task.

(If you did not perform this function please type N/A in the box below.)

Documenting procedures and events in patient medical records and departmental logs, in accordance with regulatory, hospital and departmental standards.

List the name of your Employer/Agency, your Supervisor, and his or her contact information along with the dates of employment where you gained the experience indicated above.

Also list your Position or Job Title at the time the task was performed and the number of months/years you performed the task.

(If you did not perform this function please type N/A in the box below.)

Assisted physicians in preparing and/or administering contrast media.

List the name of your Employer/Agency, your Supervisor, and his or her contact information along with the dates of employment where you gained the experience indicated above.

Also list your Position or Job Title at the time the task was performed and the number of months/years you performed the task.

(If you did not perform this function please type N/A in the box below.)

Assisted in training and evaluation of imaging technologist students and/or interns.

List the name of your Employer/Agency, your Supervisor, and his or her contact information along with the dates of employment where you gained the experience indicated above.

Also list your Position or Job Title at the time the task was performed and the number of months/years you performed the task.

(If you did not perform this function please type N/A in the box below.)

Participated in quality control and assurance procedures, including quality improvement projects.

List the name of your Employer/Agency, your Supervisor, and his or her contact information along with the dates of employment where you gained the experience indicated above.

Also list your Position or Job Title at the time the task was performed and the number of months/years you performed the task.

(If you did not perform this function please type N/A in the box below.)

Maintained patient medical records and data integrity using radiology IT systems.

List the name of your Employer/Agency, your Supervisor, and his or her contact information along with the dates of employment where you gained the experience indicated above.

Also list your Position or Job Title at the time the task was performed and the number of months/years you performed the task.

(If you did not perform this function please type N/A in the box below.)

Performed charge technologist duties.

List the name of your Employer/Agency, your Supervisor, and his or her contact information along with the dates of employment where you gained the experience indicated above.

Also list your Position or Job Title at the time the task was performed and the number of months/years you performed the task.

(If you did not perform this function please type N/A in the box below.)

Do you have experience working in a trauma center?

If you indicated yes, that you have experience working in a trauma center, what trauma level was the hospital that you worked in? (if you worked in multiple trauma centers, please select the highest level of the hospitals that you worked in).

Do you have firsthand experience utilizing any of the following equipment/ techniques (check all that apply)?

Have you been involved in a process improvement strategy to streamline an organizational process? (Such as implementing Lean Management for a hospital).

If you indicated yes, that you have been involved in a process improvement strategy, please describe the process that was utilized and your role in the project.

Also include the name of your Employer/Agency, your Supervisor, and his or her contact information along with the dates of employment where you gained the experience indicated above.

Please also list your Position or Job Title at the time the task was performed and the number of months/years you performed the task.

(If you indicated no, that you have been involved in a process improvement strategy, type “N/A” in the box below.)

INSTRUCTIONS: The purpose of this portion of the Supplemental Questionnaire is to determine if you possess creditable work experience under the Job Experience Credit (JEC) program.

I certify as true that, during the last two years, I acquired at least 6 months (1040 hours or more) of experience performing general diagnostic imaging procedures on all age groups for outpatient, inpatient and emergency/trauma patients, including gastrointestinal (GI), genitourinary (GU), skeletal, thoracic and trauma imaging procedures; assessing general patient condition; documenting medical and department records of procedures and events; transporting patients; assisting radiologists in the administration of contrast media; and assisting in the training of student imaging technologists: