Official SealHuman Resource Services Department

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. Additionally, your responses will also be evaluated and used in the selection process in order to identify the best qualified applicants. 

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 identify the best qualified candidates for this position.  Only the best and most suitably qualified candidates will be invited to participate in the oral interviews. 

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

By selecting yes below, you certify your understanding of the following:

  • This is an accelerated, continuous recruitment that may close at any time after remaining open for 25 days.
  • The applications and Supplemental Questionnaires of those candidates who possess the minimum qualifications for the class will be placed directly on the eligible list based on an evaluation of education, training, and experience only. 
  • This recruitment may be reopened as necessary and the names of additional candidates merged onto the existing list according to an evaluation of their application material.
Yes No

This position requires Board certification in Child Psychiatry or successful completion of a fellowship in Child Psychiatry.  Please specify (in detail) how you meet this requirement. Be sure to include what year and where you satisfied your Board certification and/or your fellowship.


This position requires possession of a license in good standing to practice medicine in the State of California.  Please provide your California state medical license serial number #, issue and expiration dates in the space provided below.


In the space provided below, please describe any additional job-related training and/or education you possess beyond that required by the minimum qualifications.


In compliance with the Administrative Simplification provision of the Health Insurance and Accountability Act of 1996 (HIPAA), employees in this classification are required to possess a National Provider Identifier (NPI) number prior to their first day on the job.  Do you understand this statement and are you able to meet this requirement?

Yes No

In compliance with Medicare regulations, employees 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 this statement and are you able to meet this requirement?

Yes No

Do you claim veterans’ service-connected disability?

Yes No

Do you claim veterans’ preference points?

Yes No

I understand that to claim veterans’ preference points, I MUST attach a copy of honorable discharge (DD-214) verification to my application material.  I further understand that if I claim service-connected disability, I MUST also attach proof from the Veteran’s Administration of current disability of 10% or more.

Yes No