Official SealHuman Resource Services Department


#19-6510-01
Supplemental Questionnaire

Last Name
First Name
 

Applicants for this position are required to submit responses to the following supplemental questions.  Your completed responses to the 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.  A lack of detail and explanation in the supplemental questions and in your application may result in failure or disqualification for this position.  Clarity of expression, content, experience, 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 properly completed responses.

Information provided in your responses to the supplemental questionnaire regarding your employment experiences must also be detailed in the Work Experience section of the application for this recruitment.  Please be sure to list all employers and required information, on your application, especially if you are referencing those employers in your responses to the supplemental questions.

The supplemental questions were designed to elicit your experience as it relates to the current recruitment in order to further screen for minimum qualifications for this position.

By selecting yes below, you certify your understanding that all applicants who meet minimum qualifications are not guaranteed to move forward in the process.  

Do you understand the above statement?

Yes No
1

This position requires possession of a valid clinical license in good standing from the one of the applicable licensing authority: California Board of Behavioral Sciences, California Board of Psychology, or California Board of Nursing.
 Valid licenses include the following:
•Licensed Clinical Social Worker
•Licensed Marriage & Family Therapist
•Licensed Professional Clinical Counselor
•Licensed Psychologist
•Licensed Nurse Practitioner
•Licensed Clinical Nurse Specialist

In the space below, please provide the following information related to each of the qualifying clinical licenses listed above that you possess which best qualifies you for this position:
•License Title
•License Effective Date
•License Expiration Date

2

Do you have additional job-related training and/or education beyond that required by the minimum qualifications?

If yes, indicate additional training/education below.

3

Please describe in detail your post license experience as a behavioral health/mental health clinician providing clinical and/or case management services specifically in a behavioral health managed care or related setting.  In your response please include the following:

•Employer name
•Job Title
•Start date & end date of employment
•Hours worked per week
•Your specific role/responsibility

4

To claim veterans’ preference points, you must upload a copy of your honorable discharge (DD-214) form to this application or email it to nicole.lewis-bolton@acgov.org.  Please note that proof must be received within three (3) business days from the date you apply, otherwise preference points will not be awarded.

Do you claim veterans’ preference points?

Yes No
5

To claim veterans' preference points related to a service-connected disability attach proof from the Veteran's Administration of your current disability of 10% or more by uploading it to your application or emailing to nicole.lewis-bolton@acgov.org. Please note that proof must be received within three (3) business days from the date you apply, otherwise preference points will not be awarded.
Do you claim veterans' preference points related to a service-connected disability?

Yes No
6

I understand in compliance with the Administrative Simplification provision of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as a condition of employment that employees in this classification are required to possess a National Provider Identifier (NPI) number prior to their first day on the job and I am able to meet this requirement. 

Yes No
7

In compliance with Medicare regulations, eligible licensed clinicians in this classification are required to complete the "Medicare Enrollment Process for Physicians and Non-Physician Practitioners" through the Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services, prior to their first day on the job. Active enrollment in Medicare is a condition of employment. Failure to attain or maintain active enrollment will result in termination.
Do you understand that if you are identified as an eligible licensed clinician you will be required to meet this standard?

Yes No