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#0523-RB6900-01
Supplemental Questionnaire

Last Name
First Name
1.

Pattern I

Do you possess a bachelor's degree from an accredited college or university in public health, epidemiology, biostatistics, or a related public health field with coursework in both epidemiology and biostatistics?

Yes No
1a.

If you answered Yes, please provide the following information:

  • Name of college or university you attended
  • Degree obtained
  • Major
1b.

In the space provided below, list the coursework you took in both epidemiology and biostatistics, and provide a summary of the course descriptions.

2.

Describe your experience in designing and conducting epidemiological investigations or studies and interpreting epidemiological or demographic data.  Include the name of your employer, dates of employment, job title, job duties performed, and number of hours worked per week.

3.

Pattern II

Do you possess a master's degree from an accredited college or university in epidemiology, biostatistics or a related public health field (with a minimum of one year of course work in epidemiology and one year in biostatistics)?

Yes No
3a.

If you answered Yes, please provide the following information:

  • Name of college or university you attended
  • Degree obtained
  • Major
3b.

In the space provided below, please list the coursework you completed in both epidemiology and biostatistics and provide a summary of the course descriptions.  Include course dates (start and end).

4.

This position requires possession of a valid California driver's license.  Please provide your license number and expiration date.