Official SealSan Joaquin County Human Resources Division


#0824-RS2011-AC
Supplemental Questionnaire

Last Name
First Name

 

You are applying for a position in Correctional Health Services, which provides health care to adult inmates at the San Joaquin County jail facility.

A candidate must successfully pass the security clearance, initiated through a background investigation conducted by the Sheriff’s Office. The background investigation requires the completion of an extensive questionnaire called “Personal History Questionnaire” and is used by the Sheriff’s Office to conduct the background investigation. 

The security clearance is a mandatory condition of employment, and the loss of the security clearance could result in termination from County employment in accordance with the rules and regulations governing County employment.


 

I understand that if I successfully pass the background investigation and obtain the security clearance, I will be expected to maintain my security clearance as a condition of my employment and failure to do so will result in the termination of my employment with the County in accordance with County rules and regulations

Yes No

 

Employees hired by the County must obtain California licensure as a Licensed Clinical Social Worker (LCSW), Marriage and Family Therapist (MFT) or Licensed Professional Clinical Counselor (LPCC) within five (5) years of appointment. Failure to meet these requirements may result in disciplinary action, up to and including dismissal from employment.


1.

Did you graduate from an accredited college or university with a master's degree in social work, counseling, psychology or related field?

Yes No
 

Please provide the following information about your master's degree:

  • College/University attended
  • Major
2.

Must have the ability to obtain and maintain  registration with the State of California Board of Behavioral Sciences as an Associate Clinical Social Worker (ASW), Marriage and Family Therapist Intern (MFTI), or Professional Clinical Counselor Intern (PCCI).

If currently registered or licensed, provide your registration/license number and expiration date in the space below. 

Pending application for registration will be accepted, however you must provide evidence of registration.  Please upload the evidence of registration with BBS.  If not registered, please enter the anticipated registration date below. 

 

3.

Candidates must possess and maintain a valid California driver's license.  Provide your valid California driver's license number and expiration date.