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#0821-RH6203-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.


1.

This position requires possession of a current license as a Physical Therapist issued by the Physical Therapy Board of California (PTBOC).  Do you possess this license?

Yes No
 

If you answered Yes, provide your current Physical Therapist license number issued by PTBOC, and the expiration date.

Note:  This information will be source verified.

2.

PATTERN I

To qualify under this pattern, you must have at least one year of full-time paid work experience as a Physical Therapist in San Joaquin County service.  Do you possess at least one year of full-time paid work experience as a Physical Therapist with San Joaquin County?

Yes No
 

If you answered Yes, please identify the San Joaquin County department you worked for as a Physical Therapist, dates of employment, and number of hours worked per week:

3.

PATTERN II

To qualify under this pattern, you must have two years of full-time paid progressively responsible work experience as a licensed physical therapist performing diagnostic and therapeutic physical therapy techniques for a variety of disabling conditions.  Do you possess this experience?

Yes No
 

If you answered Yes, please describe your work experience and include the following information and indicate if pthe experience was paid, volunteer, or intern:

  • Name of employer
  • Employment dates
  • Number of hours worked per week
  • Specific job duties performed

Note:  To qualify under this experience pattern, you must complete this section.  A resume is not accepted in lieu of completing, or as a response to, this question.  Providing all information requested will assist in assessing your qualifications.

4.

Possession of a valid California driver's license may be required by the nature of the assignment.  Please provide your driver's license number and expiration date.