Official SealSan Joaquin County Human Resources Division


#0621-RH0100-01
Supplemental Questionnaire

Last Name
First Name
1.

Do you possess a minimum of three years of progressively responsible experience in the administration and management of medical staff office functions in an acute care hospital?
Yes No
 

If yes, please indicate:

  • Name of each employer where the experience was gained,
  • start and end dates of employment,
  • number of hours worked per week,
  • and description of duties performed.
2.

Do you possess a valid Certified Provider Credentialing Specialist (CPCS) certificate issued by the National Association of Medical Staff Services?
Yes No
 

If yes, list the certification date and expiration date.