Official SealSan Joaquin County Human Resources Division

Supplemental Questionnaire

Last Name
First Name


Have you completed a Hemodialysis Training Program that has been approved by the State of California? 

Yes No

Professional Certification:

Are you currently Certified as a Hemodialysis Technician (CHT) by the State of California?

Yes No

I understand that I must attach a copy of my certification. 


If no, please indicate if you have the ability to obtainCalifornia certification as a Hemodialysis Technician within six (6) months after training program has been completed.

Also indicate:

  • The date you completed your training program and
  • The date you applied with the State of California to become certifed as a Hemodialysis Technician.