Official SealSan Joaquin County Human Resources Division


#0125-RS1021-AC
Supplemental Questionnaire

Last Name
First Name
1.

This position requires completion of 30 semester or 45 quarter units from an accredited college or university which included 12 semester or 15 quarter units in psychology, sociology, counseling, chemical dependency or a closely related field.

Have you successfully completed the required units as stated above?

 

Yes No
1a.

If you answered "yes" to the question above. Please state the name of the college or university you attended and list the course you have completed including the units. Indicate if semester or quarter units.

EXAMPLE: Psych 1 - Intro to Psychology 3 units (semester)

2.

Are you available and willing to work a rotating shift which includes nights, weekends and holidays?

Yes No
3.

Special Requirement

Applicants shall have registered for Alcohol and Other Drug (AOD) Counselor certification in accordance with California Code of Regulations, Title 9, Chapter 8, commencing with Section 13000.

Incumbents are required to obtain an AOD certificate issued by a certifying organization approved by the State of California within five years of appointment. Failure to obtain AOD certification within the required time-frame may result in release from employment.

By checking the box, I am indicating that I have read and understood the requirements as stated above.

3a.

Please indicate where you have registered for the Alcohol and Other Drug (AOD) Counselor certification:

CCAPP - California Consortium of Addiction Programs and Professionals
ACCBC - Addiction Counselor Certification Board of California
Other (indicate below)
3b.

If selected "Other", please provide the name below:

Note: If this does not apply to you, type "N/A"

3c.

Please provide your registration number or credential ID: