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#CCT-2454-901331
Supplemental Questionnaire

Last Name
First Name

 

The purpose of this Supplemental Questionnaire is to determine your knowledge, skills and abilities in job-related areas that have been identified as critical for satisfactory performance for positions in Class 2454 Clinical Pharmacist.

Responses to supplemental questionnaire items must be supported by the information in the body of your application (i.e. included in the Education and Training and Employment Record sections) in order to receive appropriate credit, and are subject to verification. Verification of experience, licensure, and possession of valid certifications/certificates may be collected at any time during or after the selection process.

Your responses will be used to assist in determining your score and rank on the eligible list, and will be made available to departmental personnel and management staff to assist in their hiring decisions.

Please indicate your self-assessment of training and/or work experience in the following areas:


1.

Recently (within the last 3 years) served on Pharmacy & Therapeutics (P&T) Committee or P&T Subcommittee

No
Yes
2.

Recently (within the last 3 years) provided direct patient/client care

No training and/or work experience
Up to one (1) year of training and/or work experience
More than one (1) year of training and/or work experience
3.

Recent (within the last 3 years) practiced under standardized procedures/protocol

No training and/or work experience
Up to one (1) year of training and/or work experience
More than one (1) year of training and/or work experience
4.

Highest level of residency training completed

None
PGY1
PGY2
5.

Completed a fellowship training program

No
Yes
6.

Have Specialty Certification

No
Yes
7.

Recent (within the last 3 years) experience completing DUE/Drug Monograph/Quality Improvement Project

No
Yes
8.

Recent (within last 3 years) experience giving formal presentations/inservices to medical, pharmacy or nursing personnel

No
Yes
9.

Experience with documentation in an Electronic Health Record

No
Yes
10.

Supervision (giving direction to) of subordinate staff: Pharmacy Technicians, etc.

No
Yes
11.

Experience providing services to indigent/homeless and/or mental health/substance abuse patients

No
Yes
 

The question below will not be scored.  It is for informational purposes only.

Please check the appropriate boxes to indicate your interest in working in the following settings:

Acute Care
Ambulatory Care
Behavioral Health
Skilled Nursing Facility
County Jail Facility
 

CERTIFICATION:

I hereby certify that I am the author of this application and that all information presented is true and based on my background, skills and experiences.  I understand that any false, incomplete, or incorrect statements may result in my disqualification of dismissal from employment with the City and County of San Francisco.