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#CBT-2430-902269
Supplemental Questionnaire

Last Name
First Name

 

2430 Medical Evaluations Assistant

The purpose of this supplemental questionnaire is to assist in determining if you meet the specified minimum qualifications of the position(s).  All applicants are required to complete the supplemental questionnaire as part of the online process and the information you provide must be consistent with the information listed on your online application.  The supplemental questionnaire does not substitute for the online application.  All statements are subject to verification.  

Please provide all the information requested even if it may appear redundant. Do not write "see application" as a response.


1A.

Do you possess a recognized Medical Assistant Degree or Certificate?

Yes No
1B.

If you possess a recognized Medical Assistant Degree or Certificate, please indicate the univeristy or organization where you obtained your degree or certificate, as well as the date that you obtained it.

If you do not possess a recognized Medical Assistant Degree or Certificate, please type N/A.

2A.

Please indicate if you have completed any of the following training programs.

EMT (Emergency Technician) Training Program
EMT-P (Emergency Technician/Paramedic) Training Program
U.S. Military Corpsman Training Program
Other training program
I have not completed a training program
2B.

If you have indicated that you have completed a training program in question 2A, please name the university or organization where you completed your training program, as well as the date of completion.

If you have indicated that you have completed an other training program, please additionally name and describe the specific program.

If you have not completed a training program, please type N/A.

3A.

Do you possess a valid Certified Phlebotomy Technician I (CPT-1) certificate, issued by the State of California Department of Health Services?

Yes No
3B.

If you possess a valid CPT-1 certificate issued by the State of California Department of Health Services, please indicate the date you obtained your certificate, your license number, and the date that your certificate expires.

If you do not currently possess a valid CPT-1 certificate, please type N/A.

4A.

Please indicate the amount of medical assisting work experience that you possess. (2000 hours is equivalent to 1 year).

Less than one year (2000 hours)
At least one year (2000 hours) but less than two years (4000 hours)
At least two years (4000 hours) but less than three years (6000 hours)
Three years (6000 hours) or more
I have no medical assisting work experience.
4B.

Please provide the following information regarding your response to question 4A:

  • Name of your employer where experience was obtained
  • Dates experience was obtained (e.g., MM/YYYY - MM/YYYY)
  • Supervisor or manager who can verify the information as well as his or her contact information.

If you do not have experience in this area, type N/A.

4C.

Please describe, in detail, the responsibilities that you have had that demonstrate your medical assisting experience as described in 4A and 4B.

If you do not have experience in this area, type N/A.

5A.

Please indicate the amount of experience monitoring telemetry for arrhythmias that you possess. (2000 hours is equivalent to 1 year).

Less than six months (1000 hours)
At least six months (1000 hours) but less than one year (2000 hours)
At least one year (2000 hours) but less than two years (4000 hours)
Two years (4000 hours) or more
I have no experience monitoring telemetry for arrhythmias.
5B.

Please provide the following information regarding your response to question 5A:

  • Name of your employer where experience was obtained
  • Dates experience was obtained (e.g., MM/YYYY - MM/YYYY)
  • Supervisor or manager who can verify the information as well as his or her contact information.

If you do not have experience in this area, type N/A.

5C.

Please describe, in detail, the responsibilities that you have had that demonstrate your experience monitoring telemetry for arrhythmias as described in questions 5A and 5B.

If you do not have experience in this area, type N/A.

6.

I hereby certify that I am the author of this application and that all information is true based on my background, skills and experiences.  I understand that any false, incomplete or incorrect statement, regardless of when it was discovered, may result in my disqualification or dismissal from my employment with the City and County of San Francisco.  I understand and agree that any information provided is subject to verification.