Official SealSan Joaquin County Human Resources Division


#0718-RH4002-TM
Supplemental Questionnaire

Last Name
First Name
1.

The minimum experience requires one year (2,080 hours) experience equivalent to a Clinical Laboratory Scientist I in San Joaquin County. 

Please describe your Clinical Laboratory Scientist experience. When providing examples of your work, please indicate:

  • Job Title
  • Employer's Name
  • Dates of Employment
  • Hours worked per week
2.

Possession of a valid license as a Clinical Laboratory Scientist issued by the State of California Department Health is required.

Please indicate the below information:

  1. License number
  2. Expiration date

Note: License will be verified.


 

The following are self assessment questions.  Please identify the frequency in which you perform the below tasks and your level of proficiency in each area.

Definition:

Frequency = Regularly Performed, Occassional Performed, Rarely Performed, or Never Performed

Proficiency = Expert (able to train others), Proficient (may require assistance), Theory only (no practical experience), or No knowledge



3.

A. CHEMISTRY

Automated Analyzers: General Use (knowledge of controls, ref range, troubleshooting)


a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

4.
Automated Analyzers: Immunochem

a.

Please identify your proficiency level in the above area.

Expert
Proficient (may require assistance)
Theory only (no practical experience)
No Knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

5.
Urine Drug Screens

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

6.
Osmolality:  Blood/Urine

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

7.
Lead Screening

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

8.
Fetal Fibronectin

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

9.
24 hour Urines

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

10.
Occult Blood

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

11.

B.  Hematology/Coag/Urinalysis

Automated Analyzers: General Use (Knowledge of Controls, Ref Range, Troubleshooting)


a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

12.
ESR

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

13.
Manual Differentials

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

14.

Automated Retic Counts


a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

15.
Manual CSF/Body Fluids (Calculations for dilutions, differentials)

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

16.
Kit Testing (HCG, Mono spot, HIV)

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

17.
Manual macroscopic UA

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

18.
Crystal Identification - UA/Fluids

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

19.
Semen Pos Vas

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

20.

C.  Transfusion Service

Gel Cards (General use, knowledge of controls)


a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

21.
Blood Banking Procedures (Specimen acceptability; storage; release)

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

22.
ABO/Rh/Antibody Screen (Gel and/or Tube)

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

23.
Crossmatch (Electronic; Immediate spin; Extended)

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

24.
Antibody Titer

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

25.
Direct Coombs

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

26.
Antigen Typing

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

27.
Cord Blood Work Up

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

28.
Fetal Screen

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

29.
Kleihauer-Betke

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

30.
Rhogam Candidacy

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

31.
Transfusion Reaction Workup

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

32.
Thaw FFP/Cryo

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

33.
Pediatric/Neonatal Aliquots

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

34.
Emergency Release

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

35.

D.  Microbiology

Analyzers (Vitek, GenProbe; Bacti-Alert)


a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

36.
Gram Stain

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

37.
Culture Plating

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

38.
Rapid Tests Kits

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

39.
Quick Identification Tests (Strep serological; indole; coagulase; catalase)

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

40.
AFB Culture (Concentration; Stain)

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

41.
Fungal Cultures

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

42.
Manual Sensitivities (Kirby Bauer; E test; Antibiotic biogram)

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

43.
Organism Identification (Aerobic and/or anerobic)

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

44.
Wet Prep

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed

45.
India Ink

a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed
46.

I have experience with the following LIS Applications. Check mark all that applies. 

Misys
Cerner
Opitmum Lab
Meditech
Mediware
No experience in LIS Applications
a.

Please identify your proficiency level in the above area.

Expert (able to train others)
Proficient (may require assistance)
Theory only (no practical experience)
No knowledge
b.

Please identify the frequency in performing the above task.

Regularly Performed
Occasionally Performed
Rarely Performed
Never Performed
47.

I affirm that all information I have given on this supplemental questionnaire is true and accurate.

Yes No