Medical Provider Candidate Questionnaire

For physician/mid-level provider applicants only

OPPORTUNITIES:
ERHC North - Family Medicine Physician (broad spectrum/no OB)
ERHC North - Family Medicine Mid-Level Provider
ERHC Main - Family Medicine/Women's Wellness Provider (OB negotiable)

Thank you for your interest in Emergency Responders Health Center!

Please take a moment to complete this brief candidate questionnaire, and upload a PDF of your (i) current CV and (ii) cover letter in the space provided. If you experience any difficulties uploading your documents, please reach out to us at the email below.

You may direct any questions to our administrative staff at wellness@er-hc.org.

We will confirm receipt of your application within (5) business days.

Important: This application portal is for use by physician and physician extender (mid-level) candidates only. All other job-seekers are encouraged to view the ERHC Careers page found at er-hc.org, for a list of any non-medical provider openings. This application portal was created using a HIPAA-compliant web-based software application.

Question Title

* 1. Last Name

Question Title

* 2. First Name

Question Title

* 3. Credentials

Question Title

* 4. Contact Information

Street Address

Unit Number

City

State

ZIP Code

Preferred Email Address

Preferred Phone Number

Question Title

* 5. Enter your years of medical practice in outpatient primary care settings.

< 3

3 to 5

6 to 10

> 10

Question Title

* 6. Please list all medical board certifications/advanced practice nurse licensure(s).

Physician Certification/
Last Year Conferred
or Renewed:

PA/NP Licensure/
Last Year Conferred
or Renewed:

Question Title

* 7. I am licensed to practice medicine in the following states:

State

Question Title

* 8. Please select those areas in which you have direct medical experience, ranking the degree of your expertise from preliminary to extensive.
(For areas where you have no expertise to report, please leave blank.)

	(1) Preliminary Experience	(2) Moderate Experience	(3) Extensive Experience
Family Medicine	Family Medicine (1) Preliminary Experience	Family Medicine (2) Moderate Experience	Family Medicine (3) Extensive Experience
Urgent Care	Urgent Care (1) Preliminary Experience	Urgent Care (2) Moderate Experience	Urgent Care (3) Extensive Experience
Cardiac Screening/Health	Cardiac Screening/Health (1) Preliminary Experience	Cardiac Screening/Health (2) Moderate Experience	Cardiac Screening/Health (3) Extensive Experience
Pulmonary Screening/Health	Pulmonary Screening/Health (1) Preliminary Experience	Pulmonary Screening/Health (2) Moderate Experience	Pulmonary Screening/Health (3) Extensive Experience
Cancer Screening	Cancer Screening (1) Preliminary Experience	Cancer Screening (2) Moderate Experience	Cancer Screening (3) Extensive Experience
Sports Medicine	Sports Medicine (1) Preliminary Experience	Sports Medicine (2) Moderate Experience	Sports Medicine (3) Extensive Experience
Occupational Medicine	Occupational Medicine (1) Preliminary Experience	Occupational Medicine (2) Moderate Experience	Occupational Medicine (3) Extensive Experience
Infectious Disease	Infectious Disease (1) Preliminary Experience	Infectious Disease (2) Moderate Experience	Infectious Disease (3) Extensive Experience
Emergency Medicine	Emergency Medicine (1) Preliminary Experience	Emergency Medicine (2) Moderate Experience	Emergency Medicine (3) Extensive Experience
Men's Health	Men's Health (1) Preliminary Experience	Men's Health (2) Moderate Experience	Men's Health (3) Extensive Experience
Women's Health	Women's Health (1) Preliminary Experience	Women's Health (2) Moderate Experience	Women's Health (3) Extensive Experience
Adolescent Health	Adolescent Health (1) Preliminary Experience	Adolescent Health (2) Moderate Experience	Adolescent Health (3) Extensive Experience
Pediatrics	Pediatrics (1) Preliminary Experience	Pediatrics (2) Moderate Experience	Pediatrics (3) Extensive Experience
Mental/Behavioral Health Screening	Mental/Behavioral Health Screening (1) Preliminary Experience	Mental/Behavioral Health Screening (2) Moderate Experience	Mental/Behavioral Health Screening (3) Extensive Experience
Mental/Behavioral Health Treatment	Mental/Behavioral Health Treatment (1) Preliminary Experience	Mental/Behavioral Health Treatment (2) Moderate Experience	Mental/Behavioral Health Treatment (3) Extensive Experience

Question Title

* 9. Please use the space below to list additional relevant medical experience or to provide additional comments.

Question Title

* 10. Practice Locations
(Please select all that apply.)

I currently practice in northern Idaho or northeastern Washington.
(i.e., Coeur d'Alene, Spokane, or surrounding communities)

I am interested in relocating to northern Idaho or northeastern Washington.

I currently practice in southwestern Idaho.
(i.e., Boise, Meridian, or surrounding communities)

I am interested in relocating to southwestern Idaho.

Question Title

* 11. Please briefly describe any relevant prior experience in caring for, or working alongside, first responder* populations.
(*Firefighters, law enforcement officers, paramedics/EMTs, dispatchers, military responders, etc.)

Question Title

* 12. Please briefly describe any prior experience in healthcare administration, medical leadership, or other relevant leadership roles.

Question Title

* 13. How did you learn about this practice opportunity?
(IMPORTANT: Please use the open comment field to list the exact location of the posting. Thank you!)

Provider Job Board Posting (online service)

Medical Association Posting (online publication)

ERHC Website Careers Page (er-hc.org)

Personal Referral

Other (please describe below)

Please list the specific outlet(s) where you saw this practice opportunity posted, and/or the individual(s) who referred you to ERHC.

Question Title

* 14. Use this space to upload a current CV as a PDF.
(If you experience challenges, email us at wellness@er-hc.org.)

PDF file types only.

Choose File

Question Title

* 15. Use this space to upload a cover letter as a PDF.
(If you experience challenges, email us at wellness@er-hc.org.)

PDF file types only.

Choose File

Question Title

* 16. Please use the space below to provide any additional comments that you'd like to share with our hiring team.

Thank you again for your interest in ERHC!

Medical Provider Candidate Questionnaire

For physician/mid-level provider applicants only

Question Title

* 1. Last Name

Question Title

* 2. First Name

Question Title

* 3. Credentials

Question Title

* 4. Contact Information

Question Title

* 5. Enter your years of medical practice in outpatient primary care settings.

Question Title

* 6. Please list all medical board certifications/advanced practice nurse licensure(s).

Question Title

* 7. I am licensed to practice medicine in the following states:

Question Title

* 8. Please select those areas in which you have direct medical experience, ranking the degree of your expertise from preliminary to extensive. (For areas where you have no expertise to report, please leave blank.)

Question Title

* 9. Please use the space below to list additional relevant medical experience or to provide additional comments.

Question Title

* 10. Practice Locations (Please select all that apply.)

Question Title

* 11. Please briefly describe any relevant prior experience in caring for, or working alongside, first responder* populations.(*Firefighters, law enforcement officers, paramedics/EMTs, dispatchers, military responders, etc.)

Question Title

* 12. Please briefly describe any prior experience in healthcare administration, medical leadership, or other relevant leadership roles.

Question Title

* 13. How did you learn about this practice opportunity?(IMPORTANT: Please use the open comment field to list the exact location of the posting. Thank you!)

Question Title

* 14. Use this space to upload a current CV as a PDF.(If you experience challenges, email us at wellness@er-hc.org.)

Question Title

* 15. Use this space to upload a cover letter as a PDF.(If you experience challenges, email us at wellness@er-hc.org.)

Question Title

* 16. Please use the space below to provide any additional comments that you'd like to share with our hiring team.Thank you again for your interest in ERHC!

* 8. Please select those areas in which you have direct medical experience, ranking the degree of your expertise from preliminary to extensive.
(For areas where you have no expertise to report, please leave blank.)

* 10. Practice Locations
(Please select all that apply.)

* 11. Please briefly describe any relevant prior experience in caring for, or working alongside, first responder* populations.
(*Firefighters, law enforcement officers, paramedics/EMTs, dispatchers, military responders, etc.)

* 13. How did you learn about this practice opportunity?
(IMPORTANT: Please use the open comment field to list the exact location of the posting. Thank you!)

* 14. Use this space to upload a current CV as a PDF.
(If you experience challenges, email us at wellness@er-hc.org.)

* 15. Use this space to upload a cover letter as a PDF.
(If you experience challenges, email us at wellness@er-hc.org.)

* 16. Please use the space below to provide any additional comments that you'd like to share with our hiring team.

Thank you again for your interest in ERHC!