Official SealSan Joaquin County Human Resources Division


#0118-RH6204-AC
Supplemental Questionnaire

Last Name
First Name
1.

Do you possess three years of progressively responsible experience as a licensed physical therapist performing diagnostic and therapeutic physical therapy techniques for a variety of disabling conditions?

Yes No
2.

If you answered yes to the above question, provide the following:

  • Name of employer
  • Your position title
  • Dates of employment
  • Duties performed (include types of PT therapies conducted)
  • Average hours worked per week
3.

Do you possess certification in a specific treatment technique such as neurodevelopmental treatment, infant massage, Folsom Manual Therapy, or other techniques as approved by and certification acceptable to the Department of Health Care Services or San Joaquin General Hospital?

Yes No
4.

If you answered yes to the above question, provide the following:

  • Certification number
  • Date of expiration
  • Issuing agency
5.

Do you possess certification as a specialist with the American Board of Physical Therapy Specialties or other recognized speciality boards?

Yes No
6.

If you answered yes to the above question, provide the following:

  • Certification number
  • Date of expiration
7.

Do you possess a current license as a Physical Therapist issued by the Physical Therapy Board of California?

Yes No
8.

If you answered yes to the above question, provide the following:

  • License number
  • Date of expiration