Pre-Screen Questionnaire

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Interview date:

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Candidate Profile
Full name:

First NameMiddle NameLast Name
Current résumé:

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E-mail address:
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Phone Number
Format: (000) 000-0000.
Position applied to:
Please select "Other" if the position is not listed.
Work Experience & Motivation
Education & Other Credentials
Highest form of education completed:
Major:
Name of U.S. college or university:
Please select the institution most recently attended.
Name of college or university:
Please list the institution most recently attended.
Other degrees earned:
Other education completed:
List all other degrees earned, and institutions attended on separate lines.
Licenses & certifications:
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Other credentials:
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Number of credentials verified:
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Credential verification #1:
Credential verification #2:
Credential verification #3:
Credential verification notes:
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Role Related Questions
Describe how an opportunity at Hoag aligns with your career and educational goals?
Describe what you believe your main responsibilities are in this role. What skills do you currently possess that will make you successful in it?
What are your career motivators? What are important factors in considering a new opportunity? On a scale of 1-10, how satisfied are you in your current position? What would you have to change to make it a 10?
Clinical Competency Question
Department:
You're faced with a patient that presents with a high suspicion for a cardiac event (although he appears to be stable), while concurrently caring for a patient suffering from an acute stroke. The original patient now states he is short of breath although his pulse oximetry is OK and you do not observe any labored breathing. Tell us how you would make sure high quality of care is provided for both?
Please provide an example when a patient you were caring for began to decompensate. How did you recognize it, and address the situation? What resources or information did you use to assist in preventing further decompensation and ensure your patient’s safety?
You have a patient from the Catheterization Lab post PTCA, and they start to develop chest pain. What is your course of action?
Tell me about a time you had an emergency situation and how you handled it.
Outline for me the questions you would ask a patient presenting for labor evaluation?
Your patient was admitted to Hoag yesterday after suffering an acute ischemic CVA. After receiving a dose of TPA, the patient spent a night in the ICU for close observation, then transferred to 3 East (Brain and Spine). When you received the patient at shift change you assessed them to have an NIH score of 3 for Right facial droop, slurred speech, and a mild expressive aphasia. When you enter your patient’s room 2 hours later to treat their BP, you note that they seem less alert, their slurred speech and expressive aphasia are worse, and the patient reports a sudden and severe headache. What are your primary concerns for this patient? What would you do in response?
Behavioral Interview Questions
Attitude
Attitude Rating

1

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5

1 is Poor, 5 is Great
Communication
Communication Rating

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1 is Poor, 5 is Great
Compassion
Compassion Rating

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5

1 is Poor, 5 is Great
Conflict Resolution
Conflict Rating

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5

1 is Poor, 5 is Great
Creativity
Creativity Rating

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1 is Poor, 5 is Great
Critical Thinking
Critical Thinking Rating

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1 is Poor, 5 is Great
Customer Service
Customer Service Rating

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5

1 is Poor, 5 is Great
Decision Making
Decision Making Rating

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5

1 is Poor, 5 is Great
Diversity Awareness
Diversity Awareness Rating

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5

1 is Poor, 5 is Great
Financial Acumen
Financial Acumen Rating

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1 is Poor, 5 is Great
Flexibility
Flexibility Rating

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1 is Poor, 5 is Great
Integrity
Integrity Rating

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1 is Poor, 5 is Great
Leadership
Leadership Rating

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5

1 is Poor, 5 is Great
Mentoring and Motivating
Mentoring and Motivating Rating

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1 is Poor, 5 is Great
Personal Development Drive
Personal Development Drive Rating

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5

1 is Poor, 5 is Great
Process Improvement
Process Improvement Rating

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5

1 is Poor, 5 is Great
Strategic Agility
Strategic Agility Rating

1

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4

5

1 is Poor, 5 is Great
Teamwork
Teamwork Rating

1

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4

5

1 is Poor, 5 is Great
Compensation
*Current base rate/salary:
**ENTER ONLY IF DISCLOSED BY CANDIDATE**
Desired base rate/salary:
If unknown enter 0 or leave blank.
Will you be requiring health and retirement benefits?

Other
Do you live within a commutable distance?

Other
Current or recent employer name:
Comments regarding compensation:
At Hoag, we are proud to be a union-free environment with a commitment to excellence, which we encourage by rewarding excellence in our employees with pay-for-performance opportunities. Compensation adjustments are aligned to performance. Please share how these values align with your values and your consideration of Hoag.
Availability
Shift preference:

Other
Status preference:

Other
What is your availability over the next few weeks for a formal face-to-face interview?
**IF YOU HAVE ALREADY COMPLETED A FORMAL INTERVIEW TYPE N/A**
Do you have any scheduling restrictions in the coming months? Please describe below.
i.e. vacations, observances, other obligations, etc.
How soon are you available to start?
Do you have any other interviews or offers pending?
Please explain:
Recruiter Assessment and Recommendation
Years of relevant experience:
Enter 0 if less than 1 year.

1. Not a Hoag fit 2. Recommended with Condition 3. Recommended
Recruiter summary:
Role and department recommendation.
Should be Empty:

Rows	Very Satisfied	Satisfied	Somewhat Satisfied	Not Satisfied
Communication
Preparedness
Responsiveness
Engagement

(ACSW) Associate Clinical Social Worker
(ARRT) Registered Radiologic Technologist
(CET) Certified EKG Technician
(CHT) Certified Hemodialysis Technician
(CLS) Clinical Lab Scientist
(CMA) Certified Medical Assistant
(CMT) Certified Massage Therapist
(CNA) Certified Nurse Assistant
(CNS) Clinical Nurse Specialist
(CPT I) Certified Phlebotomy Technician I
(CRT) Certified Radiologic Technologist
(CST) Certified Surgical Technologist
(DO) Doctor of Osteopathic Medicine
(EEG) Electroencephalographic Technician
(EMT-B) Emergency Medical Technician-Basic
(EMT-P) Emergency Medical Technician-Paramedic
(FRT) Fluoroscopic Radiologic Technologist
(HHA) Home Health Aide
(INT) Intern Pharmacist
(LCSW) Licensed Clinical Social Worker
(LM) Licensed Midwife
(LMFT) Licensed Marriage & Family Therapist
(LVN) Licensed Vocational Nurse
(MD) Doctor of Medicine
(NA) Nurse Anesthetist
(NM) Nurse Midwife
(NM-F) Nurse Midwife Furnishing
(NP) Nurse Practitioner
(NP-F) Nurse Practitioner Furnishing
(OT) Occupational Therapist
(OTA) Occupational Therapist Assistant
(OTR/L) Occupational Therapist Registered/Licensed
(PA) Physician Assistant
(PHN) Public Health Nurse
(PT) Physical Therapist
(PTA) Physical Therapist Assistant
(RCP) Respiratory Care Practitioner
(RN) Registered Nurse
(RN-PMH) Registered Nurse-Psychiatric Mental Health
(RPh) Registered Pharmacist
(RPSGT) Registered Polysomnographic Technologist
(SGC) California Guard Card-Security
(SLP) Speech-Language Pathologist
(SLP-A) Speech-Language Pathology Assistant
(TCH) Certified Pharmacy Technician

(ABFM) American Board of Family Medicine
(ABIM) American Board of Internal Medicine
(ABOG) American Board of Obstetrics and Gynecology
(ABP) American Board of Pediatrics
(ACLS) Advanced Cardiac Life Support
(ACNPC) Acute Care Nurse Practitioner Certification
(AG-ACNP) Adult-Gerontology Acute Care Nurse Practitioner
(BLS) Basic Life Support
(CAPA) Certified Ambulatory Perianesthesia Nurse
(CAQ) Certificate of Added Qualifications in Sports Medicine
(CCM) Certified Case Manager
(CCNS) Critical Care Nurse Specialist
(CCRN) Critical Care Registered Nurse
(CCRP) Certified Cardiac Rehabilitation Professional
(CCS) Certified Coding Specialist
(CEN) Certified Emergency Nurse
(CET) Certified Electrocardiograph/EKG Technician
(CFRN) Certified Flight Registered Nurse
(CHFN) Certified Heart Failure Nurse
(CHPN) Certified Hospice and Palliative Care Nurse
(CMC) Cardiac Medicine Certification
(CMSRN) Certified Medical-Surgical Registered Nurse
(CNL) Clinical Nurse Leader
(CNML) Certified Nurse Manager and Leader
(CNOR) Certified Nurse Operating Room
(CNRN) Certified Neuroscience Registered Nurse
(CNS-CP) Clinical Nurse Specialist Perioperative Certification
(CPEN) Certified Pediatric Emergency Nurse
(CPFT) Certified Pulmonary Function Technician
(CRCST) Certified Registered Central Service Technician
(CRNA) Certified Registered Nurse Anesthetist
(CRNFA) Certified Registered Nurse First Assistant
(CRRN) Certified Rehabilitation Registered Nurse
(CSC) Cardiac Surgery Certification
(CTRN) Certified Transport Registered Nurse
(CTRS) Certified Therapeutic Recreation Specialists
(ECG) ECG & Pharmacology
(FNP-BC) Family Nurse Practitioner-Board Certified
(MAB) Management of Assaultive Behavior
(MICN) Mobile Intensive Care Nurse
(NBCOT) National Board for Certification in Occupational Therapy
(NIHSS) NIH Stroke Scale
(NPS) Neonatal/Pediatric Respiratory Specialist
(NRP) Neonatal Resuscitation Program
(OCN) Oncology Certified Nurse
(PALS) Pediatric Advanced Life Support
(PCCN) Progressive Care Nursing Certification
(RHB) Radiologic Health Branch Certified
(RRT) Registered Respiratory Therapist
(SCRN) Stroke Certified Registered Nurse
(TCRN) Trauma Certified Registered Nurse
(TNCC) Trauma Nursing Core Course

Candidate Profile

Education & Other Credentials

Role Related Questions

Clinical Competency Question

Behavioral Interview Questions

Compensation

Availability

Recruiter Assessment and Recommendation