Official SealSan Joaquin County Human Resources Division


#0618-RH5151-TM
Supplemental Questionnaire

Last Name
First Name
1.
Have you graduated from an approved ultrasound/vascular technology education program?
Yes No
 

If yes, please specify:

 

  • name of program/school:
  • start of program/school:
  • date of program completion: 
  • date certificate/degree received:
2.
Have you graduated from a two-year allied health education program that is patient-care related? 
Yes No
 
If yes, please specify:

  • name of program:
  • nature of program:
  • date completed:
  • area of specialization/focus of training:

Please note a copy of the certification(s) must be submitted with employment application.
3.
Do you possess certification as a Radiologic Technologist and/or Certification in Mammography by the Department of Health, State of California?
Yes No
 

If you answered yes, please identify:

  • License number; and
  • Date of expiration