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#PEX-2232-PH9000
Supplemental Questionnaire

Last Name
First Name

 

2232 SENIOR PHYSICIAN SPECIALIST (PEX-2232-PH9000)

SUPPLEMENTAL QUESTIONNAIRE

PLEASE READ THE FOLLOWING INSTRUCTIONS CAREFULLY

The purpose of this Supplemental Questionnaire is to determine if you possess the Minimum and Desirable Qualifications for 2232 Senior Physician Specialist positions.

If you experience technical difficulties, make note of any error messages and contact the analyst before the filing deadline. Responses should be consistent with the information on your employment application and are subject to verification.


1a.

Please select the highest level of education that you have completed.

High School Diploma or equivalent
Associate's degree
Bachelor's degree
Master's degree
Doctoral degree
None of the above
1b.

Did you complete a recognized residency program in a medical specialty area?

Yes No
 

Please identify the accredited college or university where you completed your residency and degree programs as well as the discipline/field of study and type of degree earned (e.g. Doctor of Medicine degree from the University of California, Los Angeles; Internal Medicine Residency Program completed at the University of California, San Francisco). If you haven't completed a degree or residency program as identified above, type N/A.

2a.

Do you have a valid license to practice medicine issued by the Medical Board of California or the Osteopathic Medical Board of California?

Yes No
2b.

Do you have valid Drug Enforcement Administration (DEA) registration with the United States Department of Justice?

Yes No
3a.

Please identify the medical specialty area(s) for which you have valid board certification. Select all that apply.

Internal Medicine
Family Medicine
Emergency Medicine
Geriatric Medicine
Pediatrics
Adolescent Medicine
Infectious Disease
Pulmonary
None of the above
3b.

If you do not have valid board certification as referenced in #3a above, but you are eligible, please identify the medical specialty area(s) for which you are eligible for board certification. Select all that apply.

Internal Medicine
Family Medicine
Emergency Medicine
Geriatric Medicine
Pediatrics
Adolescent Medicine
Infectious Disease
Pulmonary
None of the above
 

If you indicated that you have a valid license, registration, and/or board certification in #2 or #3 above or if your valid board certification in a medical specialty area is not represented above, please specify it and provide the following details:

  • Your license, registration, and/or board certification number;
  • Your name as it appears on your license, registration, and/or board certification; AND
  • The expiration date of your license, registration, and/or board certification

If you do not possess a valid license, registration, and/or board certification as identified above, type N/A.

4.

How much post-residency physician experience do you have practicing in the medical specialty area(s) identified above?

One (1) year of full-time experience is equivalent to 2,000 hours.

I have less than one (1) year of experience
I have at least one (1) year, but less than two (2) years of experience
I have at least two (2) years, but less than three (3) years of experience
I have at least three (3) years, but less than four (4) years of experience
I have at least four (4) years, but less than five (5) years of experience
I have five (5) years of experience or more
I do not have any experience
5.

Please identify the PRIMARY CARE DIVISION clinic/location/program(s) for which you'd like to be considered.  Select all that apply.

Balboa Teen Health Center
Castro Mission Health Center
Chinatown Public Health Center
Community Oriented Primary Care (COPC)
Curry Senior Center
Homeless Outreach Team
Larkin Street Youth Clinic
Maxine Hall Health Center
Medical Respite and Sobering Center
Ocean Park Health Center
Potrero Hill Health Center
Silver Avenue Family Health Center
Southeast Health Center
Special Programs for Youth
Tom Waddell Urgent Care Center
Tom Waddell Urban Health Center
None of the above
6.

Please identify the FORENSICS DIVISION clinic/location/program(s) for which you’d like to be considered.  Select all that apply.

County Jail One/Two
County Jail Three/Four
County Jail Five
Jail Health Services - HIV Services
None of the above
7.

Please identify the POPULATION HEALTH SERVICES DIVISION clinic/location/program(s) for which you’d like to be considered.  Select all that apply.

AIDS Seroepi & Surv Section
Bridge HIV
California Children Services/MCH/CHDP
Center for Public Health Research
Communicable Disease Control & Prevention
Emergency Preparedness and Response
Foster Care Programs
STD Prevention & Control Services
TB Clinic
None of the above
8.

Please identify the LAGUNA HONDAL HOSPITAL AND REHABILITATION CENTER clinic/location/program(s) for which you’d like to be considered.  Select all that apply.

Medical Staff - Laguna Honda Hospital
None of the above
 

I understand that checking this box will serve as my electronic signature. I certify that I am the author of this questionnaire and all information presented is true and based upon my education, training, skills, and experience. I understand and agree that any information provided is subject to verification. I also understand that any false, incomplete, or incorrect statement may result in disqualification, termination, or dismissal from employment with the City and County of San Francisco.