Official SealSan Joaquin County Human Resources Division


#1118-RS2050-TM
Supplemental Questionnaire

Last Name
First Name
1.

Some positions may be assigned to the PHF (Psychiatric Health Facility), a 24-hour inpatient facility. Are you willing to accept employment at a 24-hour inpatient facility?
Yes No
2.

Are you willing to work a rotating shift that include nights and weekends?
Yes No
3.

Are you recognized as a designated consumer of mental health services?
Yes No
4.

If you answered yes, please provide how long you were a consumer and at what agency did you receive services.

(Do not identify your mental/medical illness.)
5.

Are you an immediate family member of a consumer with serious mental health needs? 
Yes No
6.

Identify your relationship to the consumer with serious mental health needs.
Parent
Sibling
Grandparent
Cousin
Other
7.

If you selected "other", please identify your relationship to the family member with serious mental health needs.
8.

How many years has your family member been a consumer of mental health services?
9.

Identify the agency from which the family member receives/received mental health services.

Do not identify the mental/medical illness.
10.

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