Thank you for your interest in the position of Physician III. Your completed response to this supplemental questionnaire will be evaluated to determine your qualifications and must be completed properly in order to be given full consideration for the next phase in the selection process. Responses should be specific, thorough and succinct. A lack of adequate detail in the supplemental questions and in your application may result in failure or disqualification for this recruitment. Clarity of expression, grammar, spelling and the ability to follow instructions will be considered in the evaluation process. A resume will not be accepted as a substitute for a thoroughly completed employment history and supplemental responses.
1.
By selecting yes below, you certify your understanding of the following:
This is an accelerated, continuous recruitment that may close at any time after remaining open for 25 days.
The applications and Supplemental Questionnaires of those candidates who possess the minimum qualifications for the class will be placed directly on the eligible list based on an evaluation of education, training, and experience only.
This recruitment may be reopened as necessary and the names of additional candidates merged onto the existing list according to an evaluation of their application material.
Yes
No
2.
This position requires successful completion of a four year residency in psychiatry. Please indicate below how you qualify to meet this requirement. Be sure to include what year and where you satisfied your psychiatry residency requirement.
3.
This position requires possession of a license in good standing to practice medicine in the State of California. Please provide your California state medical license serial number #, issue and expiration dates in the space provided below.
4.
In the space provided below, please describe any additional job-related training and/or education you possess beyond that required by the minimum qualifications.
5.
In the space provided below, please describe your experience working as a psychiatric medical doctor after completing your residency program (if applicable). Be sure to include the number of years and where you obtained your experience.
6.
In compliance with the Administrative Simplification provision of the Health Insurance and Accountability Act of 1996 (HIPAA), employees in this classification are required to possess a National Provider Identifier (NPI) number prior to their first day on the job. Do you understand this statement and are you able to meet this requirement?
Yes
No
7.
In compliance with Medicare regulations, employees in this classification are required to complete the "Medicare Enrollment Process for Physicians and Non-Physician Practitioners" through the Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services, prior to their first day on the job. Active enrollment in Medicare is a condition of employment. Failure to attain or maintain active enrollment will result in termination. Do you understand this statement and are you able to meet this requirement?
Yes
No
8.
Do you claim veterans’ service connected disability?
Yes
No
9.
Do you claim veterans’ preference points?
Yes
No
10
I understand that to claim veterans’ preference points, I MUST attach a copy of honorable discharge (DD-214) verification to my application material. I further understand that if I claim service-connected disability, I MUST also attach proof from the Veteran’s Administration of current disability of 10% or more.
Human Resource Services Department