Official SealSan Joaquin County Human Resources Division


#0624-RS0201-01
Supplemental Questionnaire

Last Name
First Name
1.

Do you possess a valid California driver's license?

Yes No
1a.

If you answered "Yes" to Question No. 1, please provide your California driver's license number and the expiration date.

 

PATTERN I

2.   This position requires possession of either (1) a Master's Degree from an accredited school of social work based on a two year program which included supervised field placement; or (2) a Master's Degree in Counseling from an accredited college or university with a specialization in Marriage, Family and Child Counseling based on a two year program with course work sufficient to meet State of California standards for an M.F.C.C. license and which included supervised field placement.

If you possess a Master's Degree required for the position, please provide the following information:

  • Master's Degree obtained
  • Name of institution where Master's was obtained
3.

This position requires two years of progressively responsible, post Master's Degree experience providing counseling, case management, development of assistance programs or other health services to clients in a public health program.

If you possess the required experience, please provide information on your paid work experience. For each job, provide the name of your employer, job title, dates of employment, hours worked per week and a detailed description of the job duties you performed.

 

PATTERN II

4.  Do you possess a Bachelor's Degree in Nursing from accredited college or university?

Yes No
4a.

If you answered "Yes" to Question No. 4, please provide the name of the accredited college or university you obtained your Bachelor's Degree in Nursing.

5.

This pattern requires possession of a valid Public Health Nurse license issued by the State of California Board of Registered Nursing.

Please provide your license number and expiration date.

6.

This pattern requires four years of progressively responsible experience as a public health nurse, registered nurse, or social worker including one year of experience providing social, psychological, case management, development of assistance programs or other health services to clients in a public health program.

Please provide information regarding your paid work experience.  For each job, include the name of your employer, dates of employment, hours worked per week, job title and a detailed description of the job duties you performed.