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Supplemental Questionnaire

Last Name
First Name


General Services Agency - Office of the Chief Medical Examiner
2598 Assistant Medical Examiner

Supplemental Questionnaire

The purpose of this supplemental questionnaire is to determine your knowledge, skills and abilities in job-related areas. All relevant experience must be included in this supplemental questionnaire regardless if it may seem redundant. "See application or resume" is not an acceptable response. All supplemental responses should be consistent with the information provided on your application, employment record, resume and is subject to verification.


List the name of the institution from where you obtained your Doctor of Medicine or Doctor of Osteopathy degree.


List the name of the institution from where you completed your residency program approved by the American Council for Graduate Medical Education in anatomic or anatomic and clinical pathology.


Do you possess or have eligibility to obtain certification by the American Board of Pathology in anatomic or anatomic & clinical pathology?

Yes No

Do you possess or have eligibility to obtain a valid license as a Physician and Surgeon issued by the California State Board of Medical Examiners?

Yes No

Do you possess or have eligibility to sit for the examination in the subspecialty of forensic pathology issued by the American Board of Pathology?

Yes No

Do you possess a valid California class C (or higher) driver’s license?

Yes No

Do you possess specialized training or American Board of Pathology board certification in Pediatric Pathology, Cardiac Pathology or Neuropathology?

Yes No

I hereby certify that I am the sole author of this supplemental questionnaire and that all information provided is true and is based on my background and experience. Any information provided on my application and supplemental questionnaire is subject to verification. Furthermore, I understand that any false, incomplete, or incorrect information, regardless of when it is discovered, may result in my disqualification and/or dismissal from employment with the City & County of San Francisco.

Yes No