San Joaquin County Human Resources Division
#0518-RH0851-TM
Supplemental Questionnaire
| Last Name | |
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| First Name |
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1 Pattern I Please indicate if you possess at least six months of full-time (40 hours per week) paid experience performing the following duties in a medical setting: cleaning, decontaminating, packaging or sterilizing surgical trays and supplies. |
| Yes No |
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1a Please provide the specific duties you performed cleaning, decontaminating, packaging or sterilizing surgical trays and supplies. Include employer, dates of employment, and number of hours worked per week. |
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2 PATTERN II Please indicate if you have successfully completed one of the following: Note: The programs must have included completion of 300 hours of externship in an acute care hospital. |
| Medical Instrument Technician training program |
| Sterile Processing Technician training program |
| None of the above |
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2a Please provide the name of the school attended from which the training program was completed. (A certificate of completion must be submitted with the employment application. It can be uploaded when prompted for a resume, emailed to msneed@sjgh.org, or faxed to (209) 468-6271.) |
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2b Please identify the acute care hospital from which the 300 hours of the surgical technician or medical instrument technician externship was completed. Long term acute care (LTAC) or subacute facilities is not considered a qualifying facility. Please note: Acute care is a level of care where patients are treated for a brief acute episode of illness, for conditions that are the results of a disease or trauma, and during recovery from surgery. Acute care is generally only provided in hospitals where all of the following medical units/services are provided:
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