Official SealHuman Resource Services Department


#22-6505-02
Supplemental Questionnaire

Last Name
First Name
 

IMPORTANT:  Applicants for this position are required to submit responses to the following supplemental questions. 

By selecting yes below, you certify your understanding that all applicants must meet minimum qualifications in order to move forward in the process.  Do you understand the above statement?

Yes No
1.

This position requires possession of a valid registration as an Associate Social Worker, Marriage and Family Therapist Intern, or Psychological Assistant from the applicable licensing authority: California Board of Behavioral Sciences or California Board of Psychology.   In the space below, please provide the following information related to each of the qualifying registrations listed above that you possess which best qualifies you for this position:

  • Registration Title
  • Effective Date
  • Expiration Date
2.

If applicable, please indicate your additional job-related training and/or education beyond that required by the minimum qualifications.

3.

To claim veterans’ preference points, you must upload a copy of your honorable discharge (DD-214) form to this application under the resume tab.  The resume tab can only attach one file, so if you have multiple documents, please save everything as one file and attach it once under the resume tab.  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
4.

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.  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
5.

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 can meet this requirement.

Yes No
6.

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
7.

The Detention Medical Facilities specialty designation requires indicating interest in working in a detention medical facility. Are you interested in working in a detention medical facility?

Yes No