Official SealHuman Resource Services Department

Supplemental Questionnaire

Last Name
First Name

Thank you for your interest in the position of Pediatric Occupational Therapist.  Your completed response to this supplemental questionnaire will be evaluated to determine your qualifications and must be completed properly in order to be given full consideration for the next phase in the selection process. Responses should be thorough and specific, yet concise and succinct. A lack of adequate detail in the supplemental questions and in your application may result in failure or disqualification for this recruitment. Neatness, clarity of expression, grammar, spelling and the ability to follow instructions will be considered in the evaluation process. A resume will not be accepted as a substitute for a thoroughly completed employment history and supplemental responses.

 By selecting yes below, you certify your understanding of the following:

•The applications and Supplemental Questionnaires of those candidates who possess the minimum qualifications for the class will be placed directly on the eligible list based on an evaluation of education, training, and experience only;
•This recruitment may be reopened as necessary and the names of additional candidates merged onto the existing list according to an evaluation of their application material.

Yes No

This position requires completion of an accredited course in Occupational Therapy. 

In the space provided below, please describe how you meet this standard including the educational institution where you received your degree and the type of degree received.



This position requires eligibility for, or possession of, a valid certificate to practice as a licensed Occupational Therapists from the California Board of Occupational Therapy.

In the space provided below, please provide your Occupational Therapist license number, issue and expiration date OR if you are not presently registered in California, please explain how you may be eligible.


In the space provided below, please describe any additional job-related training and/or education you possess beyond that required by the minimum qualifications.


Do you claim veterans’ preference points?

Yes No

Do you claim veterans’ service connected disability?

Yes No

I understand that in order to claim veterans’ preference points, I MUST attach a copy of honorable discharge (DD214) verification to my application material. I further understand that if I claim a service-connected disability, I MUST also attach proof from the Veteran’s Administration of current disability of 10% or more. 

Yes No