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Supplemental Questionnaire

Last Name
First Name


2587 Health Worker III (PEX-2587-080883) - Permanent Exempt

The purpose of this supplemental questionnaire is to assist in determining if you meet the specified Minimum Qualifications of the position.  The information you provide to the following questions MUST be consistent with the information on your application. Completing the supplemental questionnaire does not subsitute for the online application. All sections of the online application MUST also be completed.  All information provided is subject to verification.  

Please do not write "See Application" or "See Resume" as a response.


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 equal 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.
I do not have any experience.
I have 1 to 5 months of experience.
I have 6 to 11 months of experience.
I have 1 year to 1 year 11 months of experience.
I have 2 years to 2 years 11 months of experience.
I have 3 years to 3 years 11 months of experience.
I have 4 or more years of experience.

Please provide the following information about the work experience you indicated above. Note: Information provided MUST be consistent with the information listed on your online application.

  1. Name of employer
  2. Dates of employment (e.g. MM/YYYY-MM/YYYY)
  3. Name of supervisor or manager who can verify

If you do not have any experience, please type N/A.   


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

Yes No

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.