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#CBT-2430-902658
Supplemental Questionnaire

Last Name
First Name

 

2430 Medical Evaluations Assistant (CBT-2430-902658)

Supplemental Questionnaire

The purpose of this supplemental questionnaire is to assist in determining if you meet the specified minimum qualifications of the position(s). All applicants are required to complete the supplemental questionnaire as part of the online process and the information you provide must be consistent with the information listed on your online application.  The supplemental questionnaire does not substitute for the online application.  All statements are subject to verification.  

Please provide all the information requested even if it may appear redundant. Do not write "See application" or "See resume" as a response.


1A.

Do you possess a recognized Medical Assistant Degree or Certificate?

Yes No
1B.

If you answered "Yes" to question 1A, please provide the name of the school where you obtained your degree or certificate, as well as the date that you obtained it.

If you do not possess a recognized Medical Assistant Degree or Certificate, please type "N/A."

2A.

Please indicate if you have completed any of the following training programs:

EMT (Emergency Technician) Training Program
EMT-P (Emergency Technician/Paramedic) Training Program
U.S. Military Corpsman Training Program
Other training program
I have not completed a training program
2B.

If you indicated that you have completed a training program in question 2A, please provide the name of the school where you completed your training program, as well as the date of completion.

If you indicated that you have completed an “Other training program," please provide the name of the school where you completed your "Other training program," date of completion, name of training program, and describe the specific program.

If you selected "I have not completed a training program," please type "N/A."

3A.

Do you possess a valid Certified Phlebotomy Technician I (CPT-1) certificate, issued by the State of California Department of Health Services?

Yes No
3B.

If you answered "Yes" to question 3A, please provide your Certified Phlebotomy Technician I (CPT-1) certificate number, your name as it appears on your CPT-1 certificate, the date you obtained your certificate, and the expiration date of your certificate. (e.g. Certificate #: CPT33344433, Maggie Smith, License Obtained Date: 7/11/11, License Expiration Date: 7/11/13).

If you do not currently possess a valid CPT-1 certificate, please type "N/A."

4A.

How much medical assisting work experience do you possess? (2,000 hours is equivalent to one year.)

Less than one year (2,000 hours)
At least one year (2,000 hours) but less than two years (4,000 hours)
At least two years (4,000 hours) but less than three years (6,000 hours)
Three years (6,000 hours) or more
I have no medical assisting work experience.
4B.

Please provide the name of the employer(s) and the dates of employment (e.g. MM/YYYY - MM/YYYY) where you obtained your experience as indicated in question 4A.

In addition, please list the name of (a) supervisor(s) or manager(s) who can verify the information provided as well as their contact information. If you selected "I have no medical assisting work experience," please type "N/A."

Do not type "See resume."

4C.

Please describe, in detail, the responsibilities that you have had that demonstrate your medical assisting experience as described in 4A and 4B. If you do not have experience in this area, type "N/A."

Do not type "See resume."

5A.

How much experience monitoring telemetry for arrhythmias do you possess? (2,000 hours is equivalent to one year.)

Less than six months (1,000 hours)
At least six months (1,000 hours) but less than one year (2,000 hours)
At least one year (2,000 hours) but less than two years (4,000 hours)
Two years (4,000 hours) or more
I have no experience monitoring telemetry for arrhythmias.
5B.

Please provide the name of the employer(s) and the dates of employment (e.g. MM/YYYY - MM/YYYY) where you obtained your verifiable work experience as indicated in question 5A.

In addition, please list the name of (a) supervisor(s) or manager(s) who can verify the information provided as well as their contact information. If you did not indicate this experience above, please type "N/A."

Do not type "See resume."

5C.

Please describe, in detail, the responsibilities that you have had that demonstrate your experience monitoring telemetry for arrhythmias as described in questions 5A and 5B.

If you do not have experience in this area, type "N/A."

Do not type, "See resume."

 

I hereby certify that I am the author of this application and that all information is true based on my background, skills and experiences.  I understand that any false, incomplete or incorrect statement, regardless of when it was discovered, may result in my disqualification or dismissal from my employment with the City and County of San Francisco.  I understand and agree that any information provided is subject to verification.

Yes No