Medical Provider Candidate Questionnaire Survey

For Physician/Advanced Practice Provider applicants only

CURRENT OPPORTUNITIES:

ERHC | Family Medicine MD/DO (Boise & Nampa, Idaho)

ERHC | Family Medicine Advanced Practice Provider (Boise & Nampa, Idaho)

ERHC | Family Medicine MD/DO (Spokane, Washington)
ERHC | Family Medicine Advanced Practice Provider (Spokane, Washington)

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 medical provider 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.

1.Last Name

2.First Name

4.Contact Information

Street Address

Unit Number

City

State

ZIP Code

Preferred Email Address

Preferred Phone Number

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

< 3

3 to 5

6 to 10

> 10

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

Physician Certification/
Last Year Conferred
or Renewed:

APP Licensure (DNP, NP, PA)
Last Year Conferred
or Renewed:

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

State

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

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

I currently practice in or near Northeastern Washington/Northern Idaho.
(i.e., Spokane, Coeur d'Alene, or surrounding communities)

I am interested in relocating to Spokane/Northeastern Washington.

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

I am interested in relocating to Southwestern Idaho.

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.)

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

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/ERHC North Website Careers Page (er-hc.org)

Personal Referral*

Other (please describe below)*

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

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

No file chosen

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

No file chosen

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!