Last Name | |
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First Name |
2232 SENIOR PHYSICIAN SPECIALIST (PEX-2232-PH9000) SUPPLEMENTAL QUESTIONNAIRE PLEASE READ THE FOLLOWING INSTRUCTIONS CAREFULLY The purpose of this Supplemental Questionnaire is to determine if you possess the Minimum and Desirable Qualifications for 2232 Senior Physician Specialist positions. If you experience technical difficulties, make note of any error messages and contact the analyst before the filing deadline. Responses should be consistent with the information on your employment application and are subject to verification. |
1a. Please select the highest level of education that you have completed. |
High School Diploma or equivalent |
Associate's degree |
Bachelor's degree |
Master's degree |
Doctoral degree |
None of the above |
1b. Did you complete a recognized residency program in a medical specialty area? |
Yes No |
Please identify the accredited college or university where you completed your residency and degree programs as well as the discipline/field of study and type of degree earned (e.g. Doctor of Medicine degree from the University of California, Los Angeles; Internal Medicine Residency Program completed at the University of California, San Francisco). If you haven't completed a degree or residency program as identified above, type N/A. |
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2a. Do you have a valid license to practice medicine issued by the Medical Board of California or the Osteopathic Medical Board of California? |
Yes No |
What is the number on your medical license that returns the result, "LICENSE RENEWED & CURRENT," when searched at https://search.dca.ca.gov/? |
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What is the expiration date on your medical license? |
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2b. Do you have valid Drug Enforcement Administration (DEA) registration with the United States Department of Justice? |
Yes No |
3a. Please identify the medical specialty area(s) for which you have valid board certification. Select all that apply. |
Internal Medicine |
Family Medicine |
Emergency Medicine |
Geriatric Medicine |
Pediatrics |
Adolescent Medicine |
Infectious Disease |
Pulmonary |
None whatsoever |
Other medical specialty certification entered below |
Other medical specialty certification |
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If you do not have any board certifications yet, but you are eligible for certification, please identify the specialty. Select all that apply. |
Internal Medicine |
Family Medicine |
Emergency Medicine |
Geriatric Medicine |
Pediatrics |
Adolescent Medicine |
Infectious Disease |
Pulmonary |
ALREADY CERTIFIED |
Ineligible for any certification |
Other medical specialty entered below |
Other medical specialty eligibility |
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4. How much post-residency physician experience do you have practicing in the medical specialty area(s) identified above? One (1) year of full-time experience is equivalent to 2,000 hours. |
I have less than one (1) year of experience |
I have at least one (1) year, but less than two (2) years of experience |
I have at least two (2) years, but less than three (3) years of experience |
I have at least three (3) years, but less than four (4) years of experience |
I have at least four (4) years, but less than five (5) years of experience |
I have five (5) years of experience or more |
I do not have any experience |
5. Please identify the PRIMARY CARE DIVISION clinic/location/program(s) for which you'd like to be considered. Select all that apply. |
Balboa Teen Health Center |
Castro Mission Health Center |
Chinatown Public Health Center |
Community Oriented Primary Care (COPC) |
Curry Senior Center |
Homeless Outreach Team |
Larkin Street Youth Clinic |
Maxine Hall Health Center |
Medical Respite and Sobering Center |
Ocean Park Health Center |
Potrero Hill Health Center |
Silver Avenue Family Health Center |
Southeast Health Center |
Special Programs for Youth |
Tom Waddell Urgent Care Center |
Tom Waddell Urban Health Center |
None of the above |
6. Please identify the FORENSICS DIVISION clinic/location/program(s) for which you’d like to be considered. Select all that apply. |
County Jail One/Two |
County Jail Three/Four |
County Jail Five |
Jail Health Services - HIV Services |
None of the above |
7. Please identify the POPULATION HEALTH SERVICES DIVISION clinic/location/program(s) for which you’d like to be considered. Select all that apply. |
AIDS Seroepi & Surv Section |
Bridge HIV |
California Children Services/MCH/CHDP |
Center for Public Health Research |
Communicable Disease Control & Prevention |
Emergency Preparedness and Response |
Foster Care Programs |
STD Prevention & Control Services |
TB Clinic |
None of the above |
8. Please identify the LAGUNA HONDAL HOSPITAL AND REHABILITATION CENTER clinic/location/program(s) for which you’d like to be considered. Select all that apply. |
Medical Staff - Laguna Honda Hospital |
None of the above |
CONDITIONS OF EMPLOYMENT: I understand that if my valid license to practice medicine is issued from another state, within the United States of America, I can apply, but if selected, I will not be appointed/hired until I obtain a valid license to practice medicine issued by the Medical Board of California or the Osteopathic Medical Board of California and it must remain valid throughout the duration of employment. |
I understand that checking this box will serve as my electronic signature. I certify that I am the author of this questionnaire and all information presented is true and based upon my education, training, skills, and experience. I understand and agree that any information provided is subject to verification. I also understand that any false, incomplete, or incorrect statement may result in disqualification, termination, or dismissal from employment with the City and County of San Francisco. |