Official SealDepartment of Human Resources


#TEX-2588-904246
Supplemental Questionnaire

Last Name
First Name

 

SUPPLEMENTAL QUESTIONNAIRE
2588 Health Worker 4 (TEX-2588-904246) Temporary Exempt

The purpose of this Supplemental Questionnaire (questions #1-3) is to determine if you meet the minimum qualifications of the position.  The information you provide to the following questions does not substitute for the online application, and all information provided MUST be consistent with the information listed on your application. You must still complete all sections of the online application. Please be sure to update all sections of your application prior to submission.

All information provided is subject to verification.  Please do not write, "See Application" or "See Resume" as a response. Resumes will not be reviewed.


1.

Please indicate the total amount of experience you have performing a combination of at least two (2) of the following duties WITHIN THE LAST FIVE (5) YEARS. (Note: One year is equivalent to 2,000 hours)

  • Serving as a liaison between targeted communities and healthcare agencies;
  • Providing culturally appropriate health education/information and outreach to targeted populations;
  • Providing referral and follow up services or otherwise coordinating care;
  • Providing informal counseling, social support and advocacy to targeted populations;
  • Escorting and transporting clients;
  • Providing courier /dispatcher functions;
  • Performing pre-clinical examinations of vital statistics, such as measuring a patient’s weight, height, temperature and blood pressure.

As a reminder, all qualifying experience must be listed in the application in order to be considered in review of Minimum Qualifications. If you do not include the work experience you are about to describe in the "Work History" section of your application, you will not receive credit for this experience.  If you are copying an old application please take time to update your work history section before submitting your application. 

I have no experience.
I have less than 6 months of experience
I at least 6 months, but less than 1 year of experience
I have at least 1 year, but less than 2 years of experience
I have at least 2 years, but less than 3 years of experience
I have at least 4 years, but less than 5 years of experience
I have 5 years of more of experience
2.

For the experience you indicated above, please select the the work duties you have performed. 

As a reminder, all qualifying experience must be listed in the application in order to be considered in review of Minimum Qualifications. If you do not include the work experience you are about to describe in the "Work History" section of your application, you will not receive credit for this experience.  If you are copying an old application please take time to update your work history section before submitting your application. 

Serving as a liaison between targeted communities and healthcare agencies.
Providing culturally appropriate health education/information AND outreach to targeted populations.
Providing referral and follow up services or otherwise coordinating care.
Providing informal counseling, social support and advocacy to targeted populations.
Escorting and transporting clients.
Providing courier/dispatcher functions.
Performing pre-clinical examinations of vital statistics, such as measuring a patient's weight, height, temperature and blood pressure.
I have not performed any of the duties listed above.
3.

Do you possess a Community Health Worker certificate from City College of San Francisco?

Yes No
4.

Are you able to work some weekend shifts, and possible 12 hour shifts?

Yes No
5.

Are you willing to travel to congregate living settings where residents live in Single Residency Occupancy (SRO), Shelters, Encampments, Residential Care Facilities for the Elderly (RCFEs), Skilled Nursing Facilities (SNF), or congested housing environments?

Yes No
6.

Are you willing to go out into the field wearing PPE (Personal Protective Equipment)?

Yes No
7.

Can you speak Spanish fluently? (A language proficiency test will be administered)

Yes No
8.

Mark the appropriate box to indicate the length of your work experience with the following vulnerable population: Homelessness

0 months
1 - 6 months
7 - 12 months
13 - 24 months
24 + months
9.

Mark the appropriate box to indicate the length of your work experience with the following vulnerable population: Residents of Single Residency Occupancy (SRO)

0 months
1 - 6 months
7 - 12 months
13 - 24 months
24 + months
10.

Mark the appropriate box to indicate the length of your work experience with the following vulnerable population: Residents of Skilled Nursing Facilities (SNF)

 

0 months
1 - 6 months
7 - 12 months
13 - 24 months
24 + months
11.

Mark the appropriate box to indicate the length of your work experience with the following vulnerable population: Residents of Residential Care Facilities for Elderly (RCFEs)

0 months
1 - 6 months
7 - 12 months
13 - 24 months
24 + months
12.

Please indicate your experience in scheduling and managing staff.

0 months
1 - 6 months
7 - 12 months
13 - 24 months
24 + months
13.

Please indicate your experience in conducting interviews, summarizing and presenting findings to clinicians including nurses and doctors.

0 months
1 - 6 months
7 - 12 months
13 - 24 months
24 + months
14.

CERTIFICATION:  By checking this box, I certify that I am the author of this application and supplemental questionnaire and that all information is true based on my background, skills and experiences.  I understand that any false, incomplete or incorrect statement, regardless of when it was discovered, may result in my disqualification or dismissal from my employment with the City and County of San Francisco.  I understand and agree that any information provided is subject to verification.