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#PBT-2233-084394
Supplemental Questionnaire

Last Name
First Name

 

2233 SUPERVISING PHYSICIAN SPECIALIST (PBT-2233-084394)

DIRECTOR OF PUBLIC HEALTH EMERGENCY PREPAREDNESS AND RESPONSE

SUPPLEMENTAL QUESTIONNAIRE EXAMINATION

PLEASE READ THE FOLLOWING INSTRUCTIONS CAREFULLY

YOUR SCORES FROM THIS SUPPLEMENTAL QUESTIONNAIRE EXAMINATION WILL BE DERIVED FROM YOUR RESPONSES

The purpose of this Supplemental Questionnaire/Training and Experience Evaluation is to determine if you possess the Minimum Qualifications for the 2233 Supervising Physician Specialist – Director of Public Health Emergency Preparedness and Response as well as to determine your knowledge, skills, and abilities in job-related areas that have been identified as critical for satisfactory performance. Please refer to the examination announcement for a more detailed description of these knowledge, skills, and abilities.

The Supplemental Questionnaire/Training and Experience Evaluation will also be assessed and scored and will account for 100% of the total weight of your final score on the resulting 2233 Supervising Physician Specialist – Director of Public Health Emergency Preparedness and Response eligible list. Applicants must achieve a passing score in order to be ranked on the eligible list. Successful applicants will be placed on the eligible list, in rank order, according to their final score.

Your application or additional attached documents (e.g. resumes, cover letters, letters of reference/recommendation, etc.) will NOT be considered during the scoring process. Insufficient or non-responsive answers to the Supplemental Questionnaire may result in ineligibility, disqualification, or lower scores. Once submitted, applicant responses on the Supplemental Questionnaire cannot be changed.

It is suggested that you allow ample time to submit your application and Supplemental Questionnaire/Training and Experience Evaluation responses before the filing deadline. 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 do not possess any of the degrees identified above, type N/A.

2a.

Do you possess a valid license to practice medicine issued by the Medical Board of California or the Osteopathic Medical Board of California?

Yes No
2b.

Do you possess valid Drug Enforcement Administration (DEA) registration with the United States Department of Justice?

Yes No
2c.

Please identify the medical specialty area(s) for which you possess valid Board Certification. Select all that apply.

Internal Medicine
Family Medicine
Emergency Medicine
Preventive Medicine
Occupational Health
Geriatric Medicine
Pediatrics
Adolescent Medicine
Psychiatry
Addiction Medicine
Addiction Psychiatry
Child and Adolescent Psychiatry
Geriatric Psychiatry
None of the above
3.

How much post-residency experience do you have as a practicing Physician in Internal Medicine, Pediatrics, Family Medicine, Preventive Medicine, Occupational Health, or Emergency Medicine medical specialty areas?

One (1) year of full-time experience is equivalent to 2,000 hours.

I have some, but 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 don't have any experience
 

In accordance with your responses to #3 above, please provide the name of the employer(s) and the dates (e.g. MM/YYYY – MM/YYYY) where you obtained the verifiable full-time equivalent work experience.

Additionally, please list the name of managers or supervisors who can verify the information provided as well as their contact information. If you do not have experience in these areas, please type N/A.

4.

How much experience do you have in emergency preparedness (i.e. disaster preparedness)?

One (1) year of full-time experience is equivalent to 2,000 hours.

I have some, but 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 don't have any experience
 

In accordance with your responses to #4 above, please provide the name of the employer(s) and the dates (e.g. MM/YYYY – MM/YYYY) when you obtained the verifiable full-time equivalent work experience.

Additionally, please list the name of supervisors or managers who can verify the information provided as well as their contact information. If you do not have experience in these areas, please type N/A.

5.

Do you have experience training/developing, coaching, or mentoring employees?

Yes No
 

In accordance with your responses to #5 above, please provide the name of the employer(s) and the dates (e.g. MM/YYYY – MM/YYYY) where you obtained the verifiable full-time equivalent work experience.

Additionally, please list the name of managers or supervisors who can verify the information provided as well as their contact information. If you do not have experience in these areas, please type N/A.

6.

How much experience do you have supervising employees?

One (1) year of full-time experience is equivalent to 2,000 hours.

I have some, but 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 don't have any experience
 

In accordance with your response to #6 above, please provide the name of the employer(s) and the dates (e.g. MM/YYYY – MM/YYYY) where you obtained the verifiable full-time equivalent work experience.

Additionally, please list the name of managers or supervisors who can verify the information provided as well as their contact information. If you do not have experience in these areas, please type N/A.

7.

How much experience do you have working in a public health setting?

One (1) year of full-time experience is equivalent to 2,000 hours.

I have some, but 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 don't have any experience
 

In accordance with your response to #7 above, please provide the name of the employer(s) and the dates (e.g. MM/YYYY – MM/YYYY) where you obtained the verifiable full-time equivalent work experience.

Additionally, please list the name of managers or supervisors who can verify the information provided as well as their contact information. If you do not have experience in these areas, please type N/A.

8.

Please indicate where you’ve either made presentations or represented your agency for public health/medical related issues.  Select all that apply.

Local government department or agency
State government/regulatory department or agency
Federal government/regulatory department or agency
Emergency Medical Services related advisory board
Governing body (e.g. Board of Supervisors, health board, etc.)
Community organization
None of the above
 

In accordance with your response to #8 above, please provide the name of the employer(s) and the dates (e.g. MM/YYYY – MM/YYYY) where you obtained the verifiable full-time equivalent work experience.

Additionally, please list the name of managers or supervisors who can verify the information provided as well as their contact information. If you do not have experience in these areas, please type N/A.

9.

How much experience do you have in the areas of community engagement and/or community program planning?

One (1) year of full-time experience is equivalent to 2,000 hours.

I have some, but 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 don't have any experience
 

In accordance with your responses to #9 above, please provide the name of the employer(s) and the dates (e.g. MM/YYYY – MM/YYYY) when you obtained the verifiable full-time equivalent work experience.

Additionally, please list the name of managers or supervisors who can verify the information provided as well as their contact information. If you do not have experience in these areas, please type N/A.

10.

Have you had communicable disease experience (e.g. outbreak investigations, responding to reportable diseases, etc.)?

Yes No
 

In accordance with your responses to #10 above, please provide the name of the employer(s) and the dates (e.g. MM/YYYY – MM/YYYY) when you obtained the verifiable full-time equivalent work experience.

Additionally, please list the name of managers or supervisors who can verify the information provided as well as their contact information. If you do not have experience in these areas, please type N/A.

11.

How much experience do you have applying continuous quality improvement methods?

One (1) year of full-time experience is equivalent to 2,000 hours.

I have some, but 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 don't have any experience
 

In accordance with your responses to #11 above, please provide the name of the employer(s) and the dates (e.g. MM/YYYY – MM/YYYY) when you obtained the verifiable full-time equivalent work experience.

Additionally, please list the name of managers or supervisors who can verify the information provided as well as their contact information. If you do not have experience in these areas, please type N/A.

12.

Please identify all of the Federal Emergency Management Agency (FEMA) Incident Command System (ICS) courses that you have completed.  Select all that apply.

ICS 100: Introduction to Incident Command System
ICS 200: Incident Command System for Single Resources and Initial Action Incidents
ICS 300: Intermediate Incident Command System for Expanding Incidents
ICS 400: Advanced Incident Command System for Command and General Staff
ICS 700: National Incident Management System (NIMS), an Introduction
ICS 800: National Response Framework, an Introduction
None of the above
 

In accordance with your responses to #12 above, please provide the name of the employer(s) and the dates (e.g. MM/YYYY – MM/YYYY) when you obtained the verifiable full-time equivalent work experience.

Additionally, please list the name of managers or supervisors who can verify the information provided as well as their contact information. If you do not have experience in these areas, please type N/A.

13.

How much experience do you have directing a large or complex public health program or system?

One (1) year of full-time experience is equivalent to 2,000 hours.

I have some, but 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 don't have any experience
 

In accordance with your responses to #13 above, please provide the name of the employer(s) and the dates (e.g. MM/YYYY – MM/YYYY) when you obtained the verifiable full-time equivalent work experience.

Additionally, please list the name of managers or supervisors who can verify the information provided as well as their contact information. If you do not have experience in these areas, please type N/A.

14.

Do you have experience responding to emergencies including activating the incident command structure and coordinating with one or more agencies, city departments, or organizations?

Yes No
 

In accordance with your responses to #14 above, please provide the name of the employer(s) and the dates (e.g. MM/YYYY – MM/YYYY) when you obtained the verifiable full-time equivalent work experience.

Additionally, please list the name of managers or supervisors who can verify the information provided as well as their contact information. If you do not have experience in these areas, please type N/A.

15.

How much experience do you have overseeing and/or administering grants?

One (1) year of full-time experience is equivalent to 2,000 hours.

I have some, but 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 don't have any experience
 

In accordance with your responses to #15 above, please provide the name of the employer(s) and the dates (e.g. MM/YYYY – MM/YYYY) when you obtained the verifiable full-time equivalent work experience.

Additionally, please list the name of managers or supervisors who can verify the information provided as well as their contact information. If you do not have experience in these areas, please type N/A.

16.

Excluding residency experience, as a Physician, please identify all tools/methods you’ve used to enhance employees’ experience.  Select all that apply.

Assessment of staff engagement/satisfaction (e.g. surveys)
Regular one-on-one meetings
Team huddles
Training
Staff appreciation events
None of the above
 

In accordance with your responses to #16 above, please provide the name of the employer(s) and the dates (e.g. MM/YYYY – MM/YYYY) when you obtained the verifiable full-time equivalent work experience.

Additionally, please list the name of managers or supervisors who can verify the information provided as well as their contact information. If you do not have experience in these areas, please type N/A.

 

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.