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#1218-RS3403-01
Supplemental Questionnaire

Last Name
First Name
1.

Education/Certification: Do you possess any of the following? (Check All That Apply):

I have graduated from an accredited college or university with a Bachelor's Degree with a major in social work, sociology, psychology, counseling, or closely related field.
I have the ability to obtain a Master's Degree in Social Work from a recognized school of social work based on a two-year program that included supervised field placement. (Verification of degree must be provided prior to appointment).
I have the ability to obtain a Master's Degree from an accredited college or university in counseling with a specialization in Marriage & Family Therapy based on a two year program with coursework sufficient to meet State standards for an M.F.T. license which included supervised field placement as part of the course. (A current M.F.T. Internship number must be provided prior to appointment).
I possess an M.F.T. license with the State of California. (Will be source verified by Human Resources)
I do not possess any of the education or license certifications noted.

1A.

Based on your response(s) to Question #1, please provide the following information. If the area does not apply, simply mark “N/A” in the text box.


 

Bachelor's Degree: (List the major and college or university in which degree was obtained)

 

Master’s Degree: (List the major and college or university in which degree was obtained and month/ year received)

 

M.F.T. Internship Number, if already obtained. (Will be source verified by Human Resources with the State of California). If not yet obtained, provide date application was submitted to the State of California.

 

M.F.T. License Number. (Must be current and will be source verified by Human Resources with the State of California)

2.

Experience

Do you possess any of the following? (Check All That Apply):

Two years as a Social Worker II in San Joaquin County Service.
Three years paid post bachelor's social casework experience at a level comparable to a Social Worker in San Joaquin County.
One year of paid post-master's degree social casework experience equivalent to the class of Social Worker IV in San Joaquin County. (Please ensure you filled in the details regarding your master's in Question #1 above)
I do not possess any of the experience noted.
3.

All Social Worker positions require a valid California Driver's License. Provide the number and expiration date of your license below:

4.

This recruitment will be used to fill positions with Child Protective Services (CPS) and Adult Protective Services (APS). Please indicate your interest in referral below:

I would like to be referred for interviews in both CPS and APS.
I am only interested in being referred for interviews in CPS.
I am only interested in being referred for interviews in APS.