Official SealSan Joaquin County Human Resources Division


#0418-RH0200-TM
Supplemental Questionnaire

Last Name
First Name
1

This position requires at least two (2) years of full-time (40 hours per week; 2080 hours worked per year) paid general office clerical work, one (1) year of which included gathering personal and financial information from patients and/or families. 

The experience must have been in one of the following:  physician's office, medical clinic, or acute care hospital.  If you possess this experience, please indicate which of the facilities you are/were employed:
Physician's office
Medical clinic
Acute care hospital
All of the above
None of the above
1a

Please provide a detailed description of the one year of full-time experience gathering personal and financial information from patients/families. Comprehensively identify the specific types of personal demographics and financial information collected from patients or family members. The information provided needs to clearly identify that your role extended beyond verifying insurance and/or paymnt information. Note: Collecting co-pays is not considered qualifying experience.
1b

Was the financial and personal information gathered entered into a computerized registration system?
Yes No
2

Please indicate the number of years of experience you possess in entering and maintaining data in Excel or a similar software or database program.
less than 1 year
1 year but less than 2 years
2 years but less than 3 years
3 years but less than 4 years
over 4 years of experience
I do not possess any experience
3

SUBSTITUTION

One year of business training in an approved school or training program may be substituted for six months of general clerical experience.

Have you completed a one year business training in an approved school or training program?
Yes No
3a

If yes, please provide the following:

  • name of program/school
  • certificate/degree received
4

Some positions may require proficiency in English and other languages. Please indicate if you are fluent in English and one of the following languages:

Note: Candidates must pass a bilingual exam administered by San Joaquin County.
Cambodian
Hmong
Laotian
Spanish
Vietnamese
Other
None
4a

If you selected "other", please identify the language for you which you possess proficiency.
5

Positions to be filled may require working rotating shifts (nights, weekends, and holidays). If these positions become available, are you interested in being referred for hiring consideration? 

Note: Those indicating interest in working rotating shifts may be referred first for hiring consideration.
Yes No
 

Please indicate the departments to which you are interested in being referred:
Admitting
ER Registration
Outpatient Registration
San Joaquin County clinics
All of the above