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#0319-RH2501-AC
Supplemental Questionnaire

Last Name
First Name

 

Please complete the following supplemental questionnaire. This questionnaire is considered an extension of your employment application and will be reviewed to help assess your qualifications. Resumes are not accepted in lieu of completing this questionnaire.


1a.

This position requires completion of an accredited training program for Psychiatric Technician for entrance to testing.  Possession of a valid license as a Psychiatric Technician issued by the Board of Vocational Nurse and Psychiatric Technician examiners of the State of California is required prior to employment.  Please indicate if you have the following:

Completed an accredited training program for Psychiatric Technician
Possess a valid license as a Psychiatric Technician issued by the California Board of Vocational Nurse and Psychiatric Technicians
None of the above
1b.

If you have completed an accredited training program for Psychiatric Technician, please provide the following information:

  • Name of the college, university, or institution where you completed the program
  • Name of program
  • Date of program completion
1c.

If you possess a valid California license as a Psychiatric Technician issued by the Board of Vocational Nurse and Psychiatric Technician examiners of the State of California, please provide the following information:

  • License number
  • Expiration date
2.

Some positions may be assigned to the Psychiatric Health Facility (PHF), a 24-hour inpatient facility, or other programs which may require working rotating shifts that include nights and weekends.  Please indicate your interest in the following work schedules:

Days
Rotating
Nights (8pm to 5am)
PM (12pm to 9pm)
All Shifts