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#1018-RM0206-01
Supplemental Questionnaire

Last Name
First Name

 

 

Please answer the supplemental questions below including detailed descriptions of your experience and relevant education. Your responses to these questions will be reviewed in evaluating your qualifications.

 
1.

Do you possess at least one of the following? Please be sure that all relevant information is also included in the education portion of your application.
I possess 60 semester (or equivalent quarter) units from an accredited college or university, including at least 30 units in healthcare administration, business administration, public administration, health science, social science, behavioral science, or related field.
I possess a Bachelors degree from an accredited college or university in healthcare administration, business administration, public administration, health science, social science, behavioral science, or related field.
I possess a Masters degree from an accredited college or university in healthcare administration, business administration, public administration, health science, social science, behavioral science, or related field.
I possess a valid certificate as a residency training program coordinator from the Training Administrators of Graduate Medical Education (TAGME).
2.

Please provide a detailed description of your paid experience performing program management and analytical work in a health care environment, including details of your experience with program planning, budgeting, operations, and administrative compliance.
3.

Please provide a detailed description of your paid experience coordinating and implementing technical administrative activities for a medical residency training program, including substantial responsibility for the program's compliance with ACGME accreditation and administrative requirements.
4.

Please provide a detailed description of your required one (1) year of supervisory paid experience.  Please include employer name, number of staff supervised, your role in training and/or development of staff, assigning and overseeing workload, and your experience in conducting employee performance evaluations and employee discipline.