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#0120-RH6204-TM
Supplemental Questionnaire

Last Name
First Name

 

Copies of licenses and certifications must be submitted with the completed employment application. Failure to provide copies of the required licenses and certifications may result your application to not be considered. Copies of the licenses and certifications may be submitted when prompted to upload a resume or emailed to Bruce Cager at bcager@sjgov.org. 

 

 FOR ALL APPLICANTS
1.

Do you possess a current licensure as a Speech Pathologist issued by the California Speech-Language Pathology and Audiology and Hearing Aid Dispensers’ Board and a Certificate of Clinical Competency in Speech Pathology issued by the American Speech-Language-Hearing Association.
Yes No
 

If yes, identify the license number and certificate number and expiration dates for both the license and the certificate.

 

 

FOR SPEECH THERAPIST IV - CLINICAL APPLICANTS ONLY
2.

Either PATTERN I

Do you possess at least three years paid work experience as a licensed Speech Therapist in San Joaquin County?

If yes, identify the following:

  • Your position title
  • Employment timeline
  • Average hours worked per week

 

 

Or PATTERN II
3.

Do you possess at least four years of progressively responsible paid work experience as a licensed Speech Therapist pathologist performing diagnostic and therapeutic speech pathology techniques for a variety of disabling conditions? If yes, identify that following:

  • Name of employer
  • Position title
  • Position duties
  • Timeline of employment
  • Average hours worked per week

 

 

FOR SPEECH THERAPIST III - SENIOR  APPLICANTS ONLY
4.

EITHER PATTERN I

Experience:  Two years of progressively responsible experience as a Speech Therapist II in San Joaquin County service. If yes, provide the following:

  • Name of County department
  • Your position title
  • Position duties
  • Timeline of employment
  • Average hours worked per week

 
5.

Or PATTERN II

Experience:  Do you possess three years of progressively responsible experience as a licensed speech pathologist performing diagnostic and therapeutic speech pathology techniques for a variety of disabling conditions.  If yes, identify the following:

  • Name of employer
  • Position title
  • Duties performed
  • Timeline of employment
  • Average hours worked per week
6.

Do you possess certification as a specialist with the American Board of Physical Therapy Specialities or other recognized speciality boards?  If yes, identify the following:

  • Certification number
  • Date of expiration