Department of Human Resources

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.

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

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

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.

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

What is the number on your medical license that returns the result, "LICENSE RENEWED & CURRENT," when searched at https://search.dca.ca.gov/?

What is the expiration date on your medical license?

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

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

Other medical specialty certification

If you do not have any board certifications yet, but you are eligible for certification, please identify the specialty. Select all that apply.

Other medical specialty eligibility

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.

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

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

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

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.