Screening Questionnaire

Invitation to Complete Screening Questionnaire

Dear All the Locum Provider Professionals,

We are excited about your interest in joining our team at First Connect. To ensure the best fit for both you and the organization, we kindly invite you to complete the screening questionnaire. This questionnaire contains essential screening questions designed to help us better understand your qualifications, experience, and alignment with our company culture.

The screening questions are a crucial step in our recruitment process as they enable us to identify candidates who best meet the requirements of the role. By answering these questions accurately and thoughtfully, you’ll help us ensure that we can match you to the most suitable opportunities.

Please complete the questionnaire by at earliest, and if you have any questions, don’t hesitate to reach out to our recruitment team at Info@firstconnecthealth.com.

We look forward to learning more about you.

Best regards,
First Connect Locums

Help Us Get to Know You: Complete Our
Screening Questionnaire Today

Practice Questions: (Please skip the questions you do not wish to answer online)

How many patients are you seeing per day?

What type of patients/procedures are you currently looking?

Please name all the Procedures you are comfortable performing: (For Inpatient Services)

Practicing: What is your current call schedule?

What practice guidelines and/or protocols did you use in your daily practice at (MOST RECENT EMPLOYER)?

What types of patient conditions have most frequently presented to be seen at your most recent practice?

What practice guidelines and/or protocols do you use in your daily practice?

What EMR system you have used in Past 5 years?

Do you require any training on any EMR?

Preferences: (Please skip the questions you do not wish to answer online)

What is your location preference? Do you have any preference for how many patients would you like to see per day?

What is your Schedule preference?

What is your desired call schedule?

What kind of colleagues is it necessary for you to have in terms of back-up and professional support?

Please Answer if you are working on your own Clinic (Please skip the questions you do not wish to answer online)

How large is your office space/square footage? Will it be adequate for staff expansion?

What procedures (lab, diagnostic, etc.) are done in the office?

What equipment is available to providers in the office?

Licensing & Certifications:

Please provide License number along with Prescribing and Dispensing Privileges:

Did your professional license or certification ever been investigated or suspended?

What is your DEA Number?

Please state if DEA will be obtained or transferred?

Current Malpractice Number

Do you have any Malpractice History- add details- payouts, pending cases, settled cases and dismissals or list “no malpractice”

Any Disciplinary Actions: (Must provide detailed explanation with presentation)

BLS:

ATLS Certification:

Are you Board Certified or Board Eligible? Please provide the certification number if you are board certified

Work Experience: (Please skip the questions you do not wish to answer online)

Total FQHC or CHC Experience

Number of Years of experience as a Locum

Specialty Experience: (Please skip the questions you do not wish to answer online)

General Procedures:

Specialty Procedures:

Additional comments:

Do you have any questions for us?

Screening Questionnaire

Invitation to Complete Screening Questionnaire

Help Us Get to Know You: Complete Our Screening Questionnaire Today

Help Us Get to Know You: Complete Our
Screening Questionnaire Today