The purpose of this Supplemental Questionnaire is designed to evaluate whether candidates meet the minimum qualifications and to determine your knowledge, skills, and abilities in job-related areas that have been identified as critical for satisfactory performance.
Responses to supplemental questionnaire items must be supported by the information provided in the body of your application (i.e. education and training/employment record section) in order to receive appropriate credit, and are subject to verification. Verification of experience, licensure, and possession of valid certifications/certificates may be collected at any time during or after the selection process.
INSTRUCTIONS: Please answer all applicable questions by choosing the best response that matches your education, experience, certifications, licenses, and/or by providing the information requested.
1a.
Do you possess a valid permanent California license as a Physician Assistant issued by the California Physician Assistant Board?
Yes
No
1b.
If you answered “Yes” to question 1a., please provide your California Physician Assistant license number, your name as it appears on your license, and the expiration date of your license. If you answered “No” to question 1a., please provide an explanation below.
2a.
Do you possess a valid Drug Enforcement Agency (DEA) number to furnish controlled substances?
Yes
No
2b.
If you answered “Yes” to question 2a., please provide your Drug Enforcement Agency (DEA) number to furnish controlled substances. If you answered “No” to question 2a., please type N/A.
3a.
Which of the following valid American Heart Association Cardiopulmonary Resuscitation (CPR) certificates do you possess?
Basic Life Support (BLS) for Healthcare Provider
Advanced Cardiovascular Life Support (ACLS)
Pediatric Advanced Life Support (PALS)
Other
None
3b.
Please provide your name, certificate number, and the expiration date for each of the American Heart Association CPR certificates you selected in Question 3a. If you answered "None of the above" to question 3a., please provide an explanation.
4a.
Which of the following electronic medical records software systems do you have experience using?
Invision/LCR
ECW
JIM
EPIC
Cerner
EMAR
ISCHTR
Pulse Check
Avatar
Salar
Oaxaca
Other
None
4b.
If you selected "Other" in question 4a., please specify below.
5a.
Which of the following setting(s) have you worked as a Physician Assistant?
If you selected "Other" in question 5a., please specify below.
5c.
Please provide the name of the employer(s) and the dates of employment (e.g. MM/YYYY – MM/YYYY) for each setting you selected in question 5a.
In addition, please list the name of (a) supervisor(s) or manager(s) who can verify the information provided as well as his or her contact information. If you selected "None," please type N/A.
Do not type “See Resume.”
5d.
Referring to your answers in questions 5a., 5b. and 5c., please provide a brief description of your verifiable professional work experience as indicated in questions 5a., 5b and 5c. In your answer, include details about your specific role, your primary duties, and your responsibilities. If you do not have experience, please type N/A.
6a.
How much verifiable full-time equivalent professional, preceptorship, or volunteer work experience do you have as a health care provider serving a diverse urban population? (Full-time experience is equivalent to 40 hours per week.)
I do not have full-time equivalent professional, preceptorship, or volunteer experience working as a health care provider serving a diverse urban population.
I have some, but less than 6 months of full-time equivalent professional, preceptorship, or volunteer experience working as a health care provider serving a diverse urban population.
I have 6 - 11 months of professional, preceptorship, or volunteer experience working as a health care provider serving a diverse urban population.
I have 12 months or more full-time equivalent professional, preceptorship, or volunteer experience working as a health care provider serving a diverse urban population.
6b.
Please provide the name of the employer(s) and the dates of employment (e.g. MM/YYYY – MM/YYYY) for each setting you selected in question 6a.
In addition, please list the name of (a) supervisor(s) or manager(s) who can verify the information provided as well as his or her contact information. If you selected "None," please type N/A.
Do not type “See Resume.”
6c.
Referring to your answers in questions 6a. and 6b., please provide a brief description of your verifiable professional work experience as indicated in questions 6a. and 6b. In your answer, include details about your specific role, your primary duties, and your responsibilities. If you do not have experience, please type N/A.
7a.
How much verifiable full-time Physician Assistant work experience do you have working in a Rape Treatment Center collecting forensic evidence and providing care to survivors of sexual assault? (Full-time experience is equivalent to 40 hours per week.)
I do not have verifiable full-time Physician Assistant work experience in a Rape Treatment Center collecting forensic evidence and providing care to survivors of sexual assault.
I have less than 6 months of verifiable full-time Physician Assistant work experience in a Rape Treatment Center collecting forensic evidence and providing care to survivors of sexual assault.
I have 6-11 months of verifiable full-time Physician Assistant work experience in a Rape Treatment Center collecting forensic evidence and providing care to survivors of sexual assault.
I have 12-23 months of verifiable full-time Physician Assistant work experience in a Rape Treatment Center collecting forensic evidence and providing care to survivors of sexual assault.
I have 24 or more months of verifiable full-time Physician Assistant work experience in a Rape Treatment Center collecting forensic evidence and providing care to survivors of sexual assault.
7b.
Please provide the name of the employer(s) and the dates of employment (e.g. MM/YYYY – MM/YYYY) for each setting you selected in question 7a.
In addition, please list the name of (a) supervisor(s) or manager(s) who can verify the information provided as well as his or her contact information. If you selected "None," please type N/A.
Do not type “See Resume.”
7c.
Referring to your answers in questions 7a. and 7b., please provide a brief description of your verifiable professional work experience as indicated in questions 7a. and 7b. In your answer, include details about your specific role, your primary duties, and your responsibilities. If you do not have experience, please type N/A.
Do not type “See Resume.”
I certify that I am the author of this form and that all the information presented is true and based upon my experience. I understand that prior to an appointment I may be required to provide written verification of any of the information provided above and that I may be required by the hiring department to participate in performance test(s) during the probationary period. I further understand that any false, incomplete, or incorrect statement may result in disqualification, dismissal, or termination of employment with the City and County of San Francisco.
Department of Human Resources