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#1222-RH3200-TM
Supplemental Questionnaire

Last Name
First Name
1.

Have you completed a Medical Assistant program of training?

If yes, please be sure the education section of the application is completed in detail.
Yes No
2.

Do you possess one (1) year of experience performing the duties of a medical or outpatient clinic assistant in a medical or clinic office which included both clerical and unlicensed assistive patient care duties?
Yes No
3.

Do you possess BOTH one (1) year as a Nursing Assistant or Hospital Unit Clerk AND the equivalent of 15 units from an accredited college or approved business school in at least three (3) of the following subject areas: medical terminology, anatomy, physiology, psychology and medical office practices? 

If yes, please be sure the education section of the application is completed in detail.
Yes No
4.

Have you successfully completed an approved Paramedic (EMT-P) education program accredited in the State of California which included clinical and didactic practices?
Yes No