Official SealSan Joaquin County Human Resources Division


#1119-RH1161-TM
Supplemental Questionnaire

Last Name
First Name

 

You are applying for a position in Correctional Health Services, which provides health care to adult inmates at the San Joaquin County jail facility.

To retain employment, the candidate must successfully pass the security clearance and once employed, the employee must maintain the security clearance.

The security clearance is initiated through a background investigation conducted by the Sheriff’s Office. The background investigation requires the completion of an extensive questionnaire called “Personal History Questionnaire” and is used by the Sheriff’s Office to conduct the background investigation. 

The security clearance is a mandatory condition of employment, and the loss of the security clearance will result in termination from County employment in accordance with the rules and regulations governing County employment.


1

Have you read the above information and understand that passing and maintaining a security clearance is a condition of employment?

Yes No
2

Are you willing to submit to a background investigation conducted by the Sheriff’s Office?

Yes No
3

Have you previously had a security clearance in a detention facility or law enforcement agency?

Yes No
 

If you answered yes, provide the name of employer and dates of employment.

4

Have you failed a security clearance in the past for a detention facility or law enforcement agency?

Yes No
 

If you answered yes, provide the name of employer and date you failed the security clearance.

5

Have you ever had a security clearance revoked while employed in a detention facility or law enforcement agency?

Yes No
 

If you answered yes, provide the name of the employer and the reason your security clearance was revoked.

6

Are you willing to work with adult inmates who are incarcerated?

Yes No
7

Employment history is part of the background investigation process. Have you ever been terminated from a job or resigned from a job to avoid termination (not including involuntary layoff)?

Yes No
 

If you answered yes, provide the name of employer and date of separation

8

Disclosure of criminal history is part of the background investigation process. As an adult, have you ever been convicted for an offense other than a minor traffic violation?

No Convictions
Misdemeanor
Felony
 

If the Felony or Misdemeanor box was checked, please list date and nature of the offense

9

I understand that a thorough background investigation will be conducted as part of the selection process. I hereby certify that I have personally completed each question and that all statements are true and complete. I understand that any omissions or misstatements of facts may be considered deliberate falsification on my part, which will subject me to disqualification or, if discovered after my employment, to termination in accordance with County rules and regulations.

Yes No
10

I understand that if I successfully pass the background investigation and obtain the security clearance, I will be expected to maintain my security clearance as a condition of my employment and failure to do so will result in the termination of my employment with the County in accordance with County rules and regulations.

Yes No
11
Do you currently posses a valid Nurse Practitioner license issued by the State of California?
Yes No
 

Nurse Practitioner Certification Number:

12

Do you have one year of experience as a Nurse Practitioner?

Yes No
13

If yes, is your experience in the area of OB/GYN?

Yes No