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#0124-RH6490-AC
Supplemental Questionnaire

Last Name
First Name
 

All information within the employment application will be reviewed to help assess your qualifications.  Please be sure to complete your Employment Experience section of the application and provide a description of your PRIMARY duties.  Resumes will not be accepted in lieu of an application. 

By checking this box, you are acknowledging the statement above.
 

Have you graduated from an accrediated college or university program with a master's degree in audiology?
Yes No
 

If you answered yes, identify the following:

  • Name of accredited educational institution in which you obtained the master''s degree
  • Date of graduation
 

Do you possess current licensure as an Audiologist issued by the California Speech-Language Pathology and Audiology and Hearing Aid Dispensers' Board?
Yes No
 

If you answered yes, provide the following:

  • License number
  • Date of license expiration
 

Do you possess a current Certification of Clinical Competency in Audiology issued by either the American Speech and Hearing Association or the American Board of Audiology?
Yes No
 

If you answered yes, provide the following:

  • Certification number
  • Certification expiration date
 

Are you currently paneled as a California Children Services' Provider by the California Department of Health Care Services or eligible to apply for paneling? If yes, submit (with your employment application) evidence to validate that you meet this position requirement.  
Yes No