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First Name

Last Name

Phone

Email

Years of Experience

Are you willing to relocate?

Yes

No

Possibly, but prefer not to

What U.S. areas would you consider?

West (including Alaska & Hawaii)

Northeast

Mid-Atlantic

Southeast

Southwest

Rocky Mountain

Midwest / Plains

Great Lakes

All – Open to just about anywhere

Current Discipline

CEO / Executive Director

Operations (COO, Assistant Director, Site Manager)

Finance (CFO, Controller, Billing, etc.)

Medical Provider (MD, DO, APRN, PA)

Other Clinical (RN, LPN, LCSW, LVN)

Human Resources

Program Management

Quality

CEO / Executive Director Details

Annual budget you were responsible for:

How many FTEs were at this company?

How many years were you at this company?

Achievements

Operations Details

Needs Assessment Experience

Yes

No

How many Needs Assessments have you been part of in the last five years?

0

1-3

4-7

8 +

PCMH Experience

Yes

No

Please rate your level of expertise/knowledge of the PCMH program.

Very Experienced

Experienced

Some Experience

Not Much Experience

No Experience

Please describe what you believe to be the most important aspect of the PCMH program.

Do you have specific experience in the development of a health center’s quality assurance and quality improvement plan?

Yes

No

Finance Details

What was the size of the last budget you facilitated or participated in the creation of?

What accounting system did you last use?

Were there any findings on the last audit you participated in?

Were any restrictions placed on drawdowns from HRSA at your current or last health center?

Provider Details

Area of focus

Family Practice

Adult Medicine / Internal Medicine

Pediatrics

OB/GYN

How many years do you have providing ambulatory care in community health?

Are you interested in a Chief Medical Officer or Medical Director position?

Yes

No

Are you board certified?

Yes

No

Environment desired

Clinical Details

Were you given productivity data on a regular basis at your current or last health center?

Yes

No

Are you under a non-compete contract or have any restrictions on your work?

Yes

No

Are you in need of sponsorship by your employer?

Yes

No

Are you participating in a loan-repayment program from HRSA?

Yes

No

Human Resources Details

Does your HR department develop and deliver training on employee development?

Yes

No

What is your level of experience with the negotiation of employment contracts?

What is one area of HR that you wish you had more knowledge and experience in?

Program Management Details

How many years of direct staff management do you have?

Please share one example of a success story.

Quality Details

Please rate your level of competence in developing QI/QA plans.

Please indicate your level of expertise using population health analytics.

Do you have any experience with LEAN process improvement in a health care setting?

Yes

No

Have you participated in an Operational Site Visit?

Yes

No

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