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#CBT-2574-902538
Supplemental Questionnaire

Last Name
First Name

 

The purpose of this Supplemental Questionnaire is to determine whether you meet the required licensure and to determine your qualifications in job-related areas of the 2574 Clinical Psychologist position.

The information provided should be consistent with the information on your application and is subject to verification. Verification of work experience and licensure may be collected at any time during or after the selection process.


1

Do you possess a valid license as a Psychologist issued by the California Board of Psychology as defined in Chapter 6.6 of the Business and Professions Code, Psychology Licensing Law, Sections 2900-2903, 2914?

Yes
No
2

Are you bilingual in English and any of the languages listed below?

I am not bilingual in any other language
Spanish
Chinese (Cantonese)
Chinese (Mandarin)
Biliterate in Chinese
Biliterate in Spanish
3

Please indicate how much experience you have performing Psychological Tests

No Experience
Six to Eleven Months
Twelve to 17 Months
More than 18 Months
4

Some of our positions require that you be in the field with high risk clients to perform your work. Would you consider this type of role?

Yes No
5

Please tell us what types of clients you have experience working with as a Clinical Psychologist. List the employer(s), your title(s) and date(s) of employment where you gained this experience. If you have no experience, type N/A

6

As a licensed Clinical Psychologist, I have the following months/years (full time equivalent) of experience.

Less than 6 months full time equivalency
7 to 11 months full time equivalency
12 months to 17 months full time equivalency
More than 18 months full time equivalency
7

Tell us what settings you have experience in as a Clinical Psychologist.

Community mental health treatment programs
Public Health setting
Psychiatric Hospitals
Veterans Administration
Private Hospitals
 

I hereby certify that I am the author of this Supplemental Questionnaire and that all information presented is true and it is based on my background, skills and experience.  I understand that false, incomplete, or incorrect information may result in my disqualification or dismissal from employment with the City and County of San Francisco.  I also understand and agree that any information provided is subject to verification.