Official SealSan Joaquin County Human Resources Division


#1121-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

If you possess the required experience (at least 2 (two) years of full time paid general office clerical work), please use the space below to provide a detailed description of the one (1) year of experience gathering personal and financial information from patients in a Doctor's office, Medical Clinic or Acute Care Hospital.  Include in your answer:

1. Employer

2. Job Title

3. Dates of Employment

4. Hours worked per week

1b

Was the financial and personal information gathered from patients 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 have any experience using database programs.
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

Availability:

Please acknowledge that you understand this position will require the ability to work rotating shifts which may include nights, weekends, and holidays.

I understand that this position will require that I am available to work rotating shifts, and I am available to work this schedule.
I understand that this position will require working rotating shifts. I am unable to work this schedule.