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Placer County Human Resources Department
Mid-Level Practitioner - II
#2016-14309-01


Supplemental Questionnaire

Last Name First Name
 

 

PART I – MINIMUM QUALIFICATIONS (Not Scored)

This section will be used to determine whether minimum qualifications have been met and will not be scored.

Please select below how you meet the minimum qualifications for training:


 

Do you have the equivalent to completion of a formal Nurse Practitioner or Physician Assistant training program at an accredited educational institution?

Yes No

 

Please select below how you meet the minimum qualifications for license/certificate:


 

Do you possess a valid license as a Registered Nurse and Nurse Practitioner, Pediatric Nurse Practitioner, Family Nurse Practitioner or Family Planning Nurse Practitioner; or a valid Certificate of Letter of Approval to practice as a Physician Assistant issued by the State of California Board of Medical Quality Assurance? 

If yes, please be sure to identify any licenses and/or certificates obtained. This is located on the tab labeled "School" in the section of Certificates and Licenses of the application.

If you have a Letter of Approval to practice as a Physician Assistant, please be sure to submit a copy of the letter with your application. You may upload and attach a copy. This is located on the tab labeled "Other" when completing the application.

Yes No

 

Please select below how you meet the minimum qualifications for experience:


 

Do you have two years of Nurse Practitioner or Physician Assistant experience performing duties similar to a Mid-Level Practitioner I with Placer County?

Yes No

 

PART II – BILINGUAL LANGUAGE SKILLS (Not Scored)


 

Are you English/Spanish Bilingual? (Applicants who check “Yes” will be required to pass a Spanish Bilingual Language Skills Examination prior to being certified as Spanish Bilingual.)

 

Yes No

 

PART III – TRAINING AND EXPERIENCE RATING (Scored Examination)

Based on responses to the following questions, applicants' training and experience will be evaluated using a pre-determined formula. Scores from this evaluation will determine applicant ranking and placement on the eligible list.

For the following questions, please indicate your level of experience and/or training.


1.

Performing comprehensive physical examinations:

I possess none or a very limited amount of training and/or experience to complete this task.
I possess training and/or experience but have not applied it in a job setting.
I have experience in completing this task under close supervision.
I have experience in completing this task independently under normal supervision.
I have experience providing training and/or consultation to others with the performance of this task.
 

If you indicated training and/or experience above, please briefly describe:

2.

Independently performing laboratory and diagnostic testing in a medical setting:

I possess none or a very limited amount of training and/or experience to complete this task.
I possess training and/or experience but have not applied it in a job setting.
I have experience in completing this task under close supervision.
I have experience in completing this task independently under normal supervision.
I have experience providing training and/or consultation to others with the performance of this task.
 

If you indicated training and/or experience above, please briefly describe:

3.

Identifying medical symptoms and findings for the purpose of determining treatment or referral:

I possess none or a very limited amount of training and/or experience to complete this task.
I possess training and/or experience but have not applied it in a job setting.
I have experience in completing this task under close supervision.
I have experience in completing this task independently under normal supervision.
I have experience providing training and/or consultation to others with the performance of this task.
4.

Assisting with physicians regarding treatment of patients:

I possess none or a very limited amount of training and/or experience to complete this task.
I possess training and/or experience but have not applied it in a job setting.
I have experience in completing this task under close supervision.
I have experience in completing this task independently under normal supervision.
I have experience providing training and/or consultation to others with the performance of this task.
 

If you indicated training and/or experience above, please briefly describe:

5.

Assessing medical histories, recording findings and making evaluations of patients’ health:

I possess none or a very limited amount of training and/or experience to complete this task.
I possess training and/or experience but have not applied it in a job setting.
I have experience in completing this task under close supervision.
I have experience in completing this task independently under normal supervision.
I have experience providing training and/or consultation to others with the performance of this task.
 

If you indicated training and/or experience above, please briefly describe:

6.

Utilizing Electronic Health Record software:

I possess none or a very limited amount of training and/or experience to complete this task.
I possess training and/or experience but have not applied it in a job setting.
I have experience in completing this task under close supervision.
I have experience in completing this task independently under normal supervision.
I have experience providing training and/or consultation to others with the performance of this task.
 

If you indicated training and/or experience above, please name the system(s) used and describe your level of use, i.e. data entry, creating fields, generating reports:

7.

Independently treating superficial wounds and burns:

I possess none or a very limited amount of training and/or experience to complete this task.
I possess training and/or experience but have not applied it in a job setting.
I have experience in completing this task under close supervision.
I have experience in completing this task independently under normal supervision.
I have experience providing training and/or consultation to others with the performance of this task.
8.

Removing foreign bodies from the skin of patients:

I possess none or a very limited amount of training and/or experience to complete this task.
I possess training and/or experience but have not applied it in a job setting.
I have experience in completing this task under close supervision.
I have experience in completing this task independently under normal supervision.
I have experience providing training and/or consultation to others with the performance of this task.
9.

Incision and drainage of infections:

I possess none or a very limited amount of training and/or experience to complete this task.
I possess training and/or experience but have not applied it in a job setting.
I have experience in completing this task under close supervision.
I have experience in completing this task independently under normal supervision.
I have experience providing training and/or consultation to others with the performance of this task.
10.

Sutering of wounds and incisions:

I possess none or a very limited amount of training and/or experience to complete this task.
I possess training and/or experience but have not applied it in a job setting.
I have experience in completing this task under close supervision.
I have experience in completing this task independently under normal supervision.
I have experience providing training and/or consultation to others with the performance of this task.
11.

Using equipment and supplies appropriate to medical diagnosis and treatment:

I possess none or a very limited amount of training and/or experience to complete this task.
I possess training and/or experience but have not applied it in a job setting.
I have experience in completing this task under close supervision.
I have experience in completing this task independently under normal supervision.
I have experience providing training and/or consultation to others with the performance of this task.
12.

Developing and implementing treatment plans using medical center protocols:

I possess none or a very limited amount of training and/or experience to complete this task.
I possess training and/or experience but have not applied it in a job setting.
I have experience in completing this task under close supervision.
I have experience in completing this task independently under normal supervision.
I have experience providing training and/or consultation to others with the performance of this task.
 

If you indicated training and/or experience above, please briefly describe:

13.

Casting or splinting of sprains and simple fractures:

I possess none or a very limited amount of training and/or experience to complete this task.
I possess training and/or experience but have not applied it in a job setting.
I have experience in completing this task under close supervision.
I have experience in completing this task independently under normal supervision.
I have experience providing training and/or consultation to others with the performance of this task.
14.

Understanding and carrying out complex written and oral directions as it relates to medical treatment of patients:

I possess none or a very limited amount of training and/or experience to complete this task.
I possess training and/or experience but have not applied it in a job setting.
I have experience in completing this task under close supervision.
I have experience in completing this task independently under normal supervision.
I have experience providing training and/or consultation to others with the performance of this task.
 

If you indicated training and/or experience above, please briefly describe:

15.

Acting quickly and calmly in medical emergency situations:

I possess none or a very limited amount of training and/or experience to complete this task.
I possess training and/or experience but have not applied it in a job setting.
I have experience in completing this task under close supervision.
I have experience in completing this task independently under normal supervision.
I have experience providing training and/or consultation to others with the performance of this task.
16.

Aiding in the prevention and control of communicable diseases:

I possess none or a very limited amount of training and/or experience to complete this task.
I possess training and/or experience but have not applied it in a job setting.
I have experience in completing this task under close supervision.
I have experience in completing this task independently under normal supervision.
I have experience providing training and/or consultation to others with the performance of this task.
17.

Providing immunizations to children in a flu clinic setting:

I possess none or a very limited amount of training and/or experience to complete this task.
I possess training and/or experience but have not applied it in a job setting.
I have experience in completing this task under close supervision.
I have experience in completing this task independently under normal supervision.
I have experience providing training and/or consultation to others with the performance of this task.
18.

Providing immunizations to elderly adults in a flu clinic setting:

I possess none or a very limited amount of training and/or experience to complete this task.
I possess training and/or experience but have not applied it in a job setting.
I have experience in completing this task under close supervision.
I have experience in completing this task independently under normal supervision.
I have experience providing training and/or consultation to others with the performance of this task.
19.

Conducting Well-Child exams:

I possess none or a very limited amount of training and/or experience to complete this task.
I possess training and/or experience but have not applied it in a job setting.
I have experience in completing this task under close supervision.
I have experience in completing this task independently under normal supervision.
I have experience providing training and/or consultation to others with the performance of this task.
20.

Identifying medications and their desired effects, side effects, contra-indications and complications:

I possess none or a very limited amount of training and/or experience to complete this task.
I possess training and/or experience but have not applied it in a job setting.
I have experience in completing this task under close supervision.
I have experience in completing this task independently under normal supervision.
I have experience providing training and/or consultation to others with the performance of this task.
 

If you indicated training and/or experience above, please briefly describe:

21.

Diagnosing, instructing, and counseling patients and family members regarding medical problems:

I possess none or a very limited amount of training and/or experience to complete this task.
I possess training and/or experience but have not applied it in a job setting.
I have experience in completing this task under close supervision.
I have experience in completing this task independently under normal supervision.
I have experience providing training and/or consultation to others with the performance of this task.
 

If you indicated training and/or experience above, please briefly describe:


 

Thank you for completing the supplemental questionnaire portion of the application process. Please Save & Continue to move forward to the next tab. Be sure to select the "Submit" button once the application has been completed. You will receive confirmation that the application has been submitted.