Official SealSan Joaquin County Human Resources Division


#0425-RH5154-PC
Supplemental Questionnaire

Last Name
First Name
1

Do you currently work for San Joaquin General Hospital?
Yes No
2

Certification as a Radiologic Technologist and/or certification in Mammography by the Department of Health, State of California may be required.

Please provide your certification number
4
Please describe your full-time paid work experience performing ultrasound and/or vascular examinations.  Please specify whether it was acquired in a physician's office, clinic or hospital.
5

Have you graduated from an approved ultrasound/vascular technology education program?
Yes No
 

If yes, please specify:

 

  • name of program/school:
  • start of program/school:
  • date of program completion: 
  • date certificate/degree received:
6

Have you graduated from a two-year allied health education program that is patient care related. 
Yes No
 
If yes, please specify:

  • name of program:
  • nature of program:
  • date completed:
  • area of specialization/focus of training:

Please note a copy of the certification(s) must be submitted with employment application.
7
Are you able to demonstrate competence to perform at least three ultrasound modalities such as abdominal, cardiovascular, vascular, obstetrical/gynecological ultrasound procedures?
Yes No