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Physician - Memorial City Urology (100161803)

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Primary External Recruiting Questionnaire - 12_dot_15_dot_2023

Are you 16 years and above?

Memorial Hermann does not hire individuals who use tobacco products in any form (Cigarettes, Cigars, Cigarillos, Filtered Little Cigars, Electronic Cigarettes / E-cigarettes, Vapes, Smokeless Tobacco including chewing tobacco, snuff, dip, snus, or dissolvable tobacco, Pipes, Water Pipes, Hookahs, any combustible tobacco product, tobacco patches). Applicants who receive and accept an offer of employment will be required to complete a pre-employment test for tobacco use. An applicant whose results are verified positive for tobacco use will not be eligible for employment. Do you wish to proceed with applying for this position?

Memorial Hermann’s vaccine policy requires all new hires and employees to be vaccinated against the flu, unless they qualify for a medical or religious exemption. New hires must be fully vaccinated or be approved for an exemption prior to the first day of employment. Failure to comply with these requirements will result in a rescinded offer of employment. Do you wish to proceed with applying for this position?

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Please list all current certifications you currently possess, and their expiration date (i.e., BLS, ACLS, PMP, Six Sigma):

Do you now, or will you by the start date, meet the minimum qualifications for experience as listed in this job posting?

Do you now, or will you by the start date, have the licenses and certifications required for this position?

Do you now, or will you by the start date, have the education required for this position?

Are you legally authorized to work in the United States for any employer?

Have you ever been excluded, sanctioned, or otherwise restricted from participation in any federal or state health care program (including Medicare or Medicaid)? You have an affirmative duty as a condition of employment and/or staff privileges to immediately report any exclusion, sanction or other restriction (past, present, or future) from participation in any federal or state health care program (including Medicare or Medicaid) to the Corporate Compliance Department. Please note that any exclusion, sanction, or restriction will not necessarily disqualify an application for employment.

Are you currently being investigated by a regulatory, licensing, or government agency, or have you ever been the subject of any disciplinary or adverse action taken by a regulatory, licensing or government agency? You have an affirmative duty as a condition of employment and/or staff privileges to immediately report any disciplinary or adverse action taken (past, present, or future) by a regulatory, licensing and government agency to the Corporate Compliance Department. Examples of regulatory, licensing and government agencies include, but are not limited to, Centers for Medicare and Medicaid Services (CMS), state Medicaid programs, Department of Health and Human Services (DHHS), Office of Inspector General (OIG), and any Medical or Nursing boards. Please note that being under investigation or being the subject of disciplinary or adverse action will not necessarily disqualify an application for employment.

Do you have any family members who are current employees or on the Board of Directors for Memorial Hermann? Relationship by blood: parent, child, grandparent, grandchild, sibling, uncle, aunt, nephew, niece, and first cousin. Relationship by marriage: spouse, step-parent, step-child, in-laws, half-siblings, uncle, aunt, nephew, niece, spouse/partner of any of those listed, and co-habitating couples/significant others.

Are you currently subject to a non-compete, non-solicitation, employment agreement, or any other obligation with another employer that would prohibit your employment with Memorial Hermann Health System or any affiliated entities or that could affect your ability to perform the job for which you are applying?

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Physician - Memorial City Urology (100161803)

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Physician - Memorial City Urology (100161803)

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