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#CBT-2908-901699
Supplemental Questionnaire

Last Name
First Name

 

2908 Senior Hospital Eligibility Worker (CBT-2908-901699)

The purpose of this supplemental questionnaire is to assist in determining if you meet the specified minimum qualifications of the class 2908 Senior Hospital Eligibility Worker.  All applicants are required to complete the supplemental questionnaire as part of the online application process and the information you provide should be consistent with the information listed on your online application. Please make sure ANY information provided in the supplemental questionnaire is also on your application.  The supplemental questionnaire does NOT substitute for the online application.  All statements are subject to verification. 

  • PLEASE DO NOT COPY AND PASTE RESUME OR APPLICATION
  • PLEASE DO NOT WRITE "SEE APPLICATION" OR "SEE RESUME"

1.

How many years of verifiable experience performing the duties of an ELIGIBILITY WORKER do you possess?  (2000 hours = 1 year)

I do not possess verifiable experience performing the duties of an Eligibility Worker
I possess less than 6 months of verifiable experience performing the duties of an Eligibility Worker
I possess 6 months - 12 months of verifiable experience performing the duties of an Eligibility Worker
I possess 13 months - 18 months of verifiable experience performing the duties of an Eligibility Worker
I possess 19 months - 23 months of verifiable experience performing the duties of an Eligibility Worker
I possess 24 months - 36 months of verifiable experience performing the duties of an Eligibility Worker
I possess more than 3 years of verifiable experience performing the duties of an Eligibility Worker
2.

For the experience that you indicate above, please indicate the settings in which you worked performing the duties of an ELIGIBILITY WORKER?

Please check ALL that apply. 

HOSPITAL
MEDICAL CLINIC
MEDI-CAL UNIT
COMMUNITY-BASED HEALTH ORGANIZATION
I have experience in at least one of these settings, but NOT as an Eligiblity Worker
I do not have experience in any of these settings
 

Please provide the following information for each location setting that you have worked performing the duties of an Eligibility Worker:

  1. Name of Employer
  2. Setting (Hospital, Medical Clinic, Medi-Cal Unit, Community-Based Health Organization)
  3. Your JOB TITLE
  4. Dates of experience (MM/YYYY - MM/YYYY)
  5. Hours per week worked
  6. Contact information of supervisor or manager who can verifiy the information

If you do not have this experience, type "N/A". DO NOT copy and paste your resume or application or write "see resume" or "see application"

3.

Does your experience as an Eligibility Worker include determining eligibility for various Federal, State and County programs that reimburse for medical care? (2000 hours = 1 year)

Yes No
 

If you answered YES to the above questions, Please provide the following information: 

  • Name of Program(s) you DETERMINE(D) eligibility for
  • Name(s) of employer(s) where you obtained this experience
  • Dates of your experience (MM/YYYY-MM/YYYY)
  • Hours per week worked
  • Your Job Title at this employer

If you do not have this experience please type "N/A"

DO NOT write See Resume or See Attachment. DO NOT copy and paste your resume or application into this section.

 

 

CERTIFICATION: By checking this box, I hereby certify that I am the author of the information supplied in this supplemental questionnaire.  I understand that any false or incorrect statements may result in my disqualification or dismissal from employment with the San Francisco Department of Public Health and City and County of San Francisco.  I also understand and agree that the information provided is subject to verification.