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#0620-RH2060-TM
Supplemental Questionnaire

Last Name
First Name

 
Please complete the following supplemental questions for the position of Dialysis Patient Care Technician. This supplemental will be utilized to best determine your qualifications for this position.

1.

Education:

Have you completed a Hemodialysis Training Program that has been approved by the State of California? (Note, if yes, please be sure to clearly identify this information on your employment application under education or on your resume)

Yes No
2.

Professional Certification:

Are you currently Certified as a Hemodialysis Technician (CHT) by the State of California?

Yes No
 

If no, please indicate if you have the ability to obtainCalifornia certification as a Hemodialysis Technician within six (6) months after training program has been completed.

Also indicate:

  • The date you completed your training program and
  • The date you applied with the State of California to become certifed as a Hemodialysis Technician.
3.

Availability:

Please acknowledge that you understand this position will require employees to work rotating shifts.

I understand that this position will require that I am available to work rotating shifts.