Official SealSan Joaquin County Human Resources Division


#0519-RH5154-TM
Supplemental Questionnaire

Last Name
First Name
1.

Have you graduated from an approved ultrasound/vascular technology education program?

Yes No
2.

If yes, please specify:

 

  • name of program/school:
  • start of program/school:
  • date of program completion: 
  • date certificate/degree received:
3.
Have you graduated from a two-year allied health education program that is patient care related?
Yes No
4.
If yes, please specify:

  • name of program/school:
  • start of program/school:
  • date of program completion: 
  • date certificate/degree received:
  • type (ie. LVN, RN, EMT, etc.) of certificate/degree received:
5.
Please describe your full-time paid experience(s) performing abdominal ultrasound procedures. Indicate job title, employer name, employment dates, and estimated number of abdominal ultrasound procedures you completed in each employment. If you do not have experience in abdominal ultrasound procedures, indicate "none".
6.
Please describe your full-time paid experience(s) performing cardiovascular ultrasound procedures. Indicate job title, employer name, employment dates, and estimated number of cardiovascular ultrasound procedures you completed in each employment. If you do not have experience in cardiovascular ultrasound procedures, indicate "none".
7.
Please describe your full-time paid experience(s) performing vascular ultrasound procedures. Indicate job title, employer name, employment dates, and estimated number of vascular ultrasound procedures you completed in each employment. If you do not have experience in vascular ultrasound procedures, indicate "none".
8.
Please describe your full-time paid experience(s) performing obstetrical/gynecological ultrasound procedures. Indicate job title, employer name, employment dates, and estimated number of obstetrical/gynecological ultrasound procedures you completed in each employment. If you do not have experience in obstetrical/gynecological ultrasound procedures, indicate "none".
9.
Please describe your full-time paid experience(s) performing any other ultrasound procedures/examinations. Indicate job title, employer name, employment dates, and estimated number of each type of ultrasound procedures/examinations you completed in each employment. If you do not have other experience in ultrasound procedures/examinations, indicate "none".

 
The following list ultrasound procedures typically performed in diagnostic imaging.  Please indicate the level of experience and/or training received for following questions.

10.

Indicate your experience level performing abdominal ultrasound procedures in the gallbladder area.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
11.

Indicate your experience level performing abdominal ultrasound procedures in the liver area.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
12.

Indicate your experience level performing abdominal ultrasound procedures on the renal area.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
13.

Indicate your experience level performing abdominal ultrasound procedures on the pancreas area.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
14.

Indicate your experience level performing abdominal ultrasound procedures on the aorta area.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
15.

Indicate your experience level performing abdominal ultrasound procedures on the spleen area.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
16.

Indicate your experience level performing superficial parts ultrasound procedures on the thyroid area.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
17.

Indicate your experience level performing superficial parts ultrasound procedures on the testicular area.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
18.

Indicate your experience level performing superficial parts ultrasound procedures on the breast area.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
19.

Indicate your experience level performing 2nd trimester obstetric ultrasound procedures.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
20.

Indicate your experience level performing 3rd trimester obstetric ultrasound procedures.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
21.

Indicate your experience level performing gynecologic: female pelvis (non-pregnant) ultrasound procedures in the transabdominal area.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
22.

Indicate your experience level performing gynecologic: female pelvis (non-pregnant) ultrasound procedures in the endovaginal area.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
23.

Indicate your experience level performing upper extremity venous doppler vascular ultrasound procedures.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
24.

Indicate your experience level performing upper extremity arterial doppler vascular ultrasound procedures.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
25.

Indicate your experience level performing lower extremity segmental pressures with ABI calculation vascular ultrasound procedures.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
26.

Indicate your experience level performing lower extremity venous doppler vascular ultrasound procedures.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
27.

Indicate your experience level performing lower extremity arterial doppler vascular ultrasound procedures.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
28.

Indicate your experience level performing carotid doppler vascular ultrasound procedures.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
29.

Indicate your experience level performing plethysmographic (PPG, VPG, SPG) procedures.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
30.

Indicate your experience level performing echocardiography ultrasound procedures in the parasternal long axis view.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
31.

Indicate your experience level performing echocardiography ultrasound procedures in the parasternal short axis view.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
32.

Indicate your experience level performing echocardiography ultrasound procedures in the apical view.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
33.

Indicate your experience level performing echocardiography ultrasound procedures in the subcostal view.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
34.

Indicate your experience level performing echocardiography ultrasound procedures in the suprasternal view.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
35.

Indicate your experience level performing invasive ultrasound procedures for amniocentesis.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
36.

Indicate your experience level performing invasive ultrasound procedures for thoracentesis.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
37.

Indicate your experience level performing invasive ultrasound procedures for paracentesis.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
38.

Indicate your experience level performing invasive ultrasound procedures for a biopsy.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
39.

Indicate your experience level performing intraoperative invasive ultrasound procedures.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
40.

Indicate your experience level performing invasive ultrasound procedures for shunt/catheter/central line placement.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
41.

Indicate your experience level performing ultrasound procedures on neonatal heads.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.
42.

Indicate your experience level performing ultrasound procedures on neonatal spines.

I have no experience in this area.
I have studied this test in a classroom setting.
I have performed this test in a formal, on-the-job training program.
I have performed this test in a work setting.
I have trained, instructed or supervised others in the performance of this test on a regular basis.