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Supplemental Questionnaire

Last Name
First Name





The purpose of the Supplemental Questionnaire is to assist with determining if you possess the Minimum Qualifications for Laguna Honda Hospital and Rehabilitation Center's 2574 Clinical Psychologist - Neuropsychologist position.

It is suggested that you allow ample time to submit your application and Supplemental Questionnaire responses before the filing deadline. If you experience technical difficulties, make note of any error messages and contact the analyst before the filing deadline. Responses should be consistent with the information on your employment application and are subject to verification.


Please select the highest level of education that you have completed.

High School Diploma or equivalent
Associate's degree
Bachelor's degree
Master's degree
Doctoral degree
None of the above

Please list the school(s) where you obtained your degree(s), the discipline/field of study, and type of degree earned (e.g. Bachelor of Arts degree in Psychology from the San Jose State University). If you do not possess any of the degrees identified above, type N/A.


Do you have a valid license as a Psychologist issued by the California Board of Psychology?

Yes No

If you answered that you possess a valid license in #2 above, please identify your license number, your name as it appears on your license, and the expiration date of your license. If you do not possess a license as identified above, type N/A.


Have you completed two (2) years (equivalent to 4,000 hours) post-doctoral fellowships in clinical neuropsychology or two (2) years (equivalent to 4,000 hours) of experience as a clinical neuropsychologist?

IMPORTANT NOTE:  Qualifying education, training, and experience must be under the supervision of a neuropsychologist and commensurate with "The Houston Conference on Specialty Education and Training in Clinical Neuropsychology" Policy Statement

Yes No

In accordance with your responses to #3 above, please provide the name of the employer(s) and the dates (e.g. MM/YYYY – MM/YYYY) where you obtained the verifiable full-time equivalent work experience or completed your post-doctoral fellowship.

Additionally, please list the name of (a) supervisor(s) or manager(s) who can verify the information provided as well as his or her contact information. If you do not have experience in these areas, please type N/A.


I understand that checking this box will serve as my electronic signature. I certify that I am the author of this questionnaire and all information presented is true and based upon my education, training, skills, and experience. I understand and agree that any information provided is subject to verification. I also understand that any false, incomplete, or incorrect statement may result in disqualification, termination, or dismissal from employment with the City and County of San Francisco.