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#CBT-2314-902509
Supplemental Questionnaire

Last Name
First Name

 

2314 Behavioral Health Team Leader
SUPPLEMENTAL QUESTIONNAIRE

The purpose of this Supplemental Questionnaire is to determine if you meet the minimum qualifications of a 2314 Behavioral Health Team Leader, and to determine your knowledge, skills, and abilities in job-related areas that have been identified as critical for satisfactory performance in this classification.

Responses to supplemental questionnaire items must be supported by the information provided in the body of your application (i.e. education and training/employment record section) in order to receive appropriate credit, and are subject to verification. Verification of experience, licensure, and possession of valid certifications/certificates may be collected at any time during or after the selection process.

INSTRUCTIONS: Please answer all applicable questions by choosing the best response that matches your education, experience, certifications, licenses, and/or by providing the information requested.


1A.

Do you possess a valid permanent or temporary (including an interim permit) Licensed Vocational Nurse (LVN) or Licensed Psychiatric Technician (LPT) License issued by the State of California?

Yes, I have a valid permanent Licensed Vocational Nurse (LVN) or Licensed Psychiatric Technician (LPT) License issued by the State of California
Yes, I have a valid temporary (including an interim permit) Licensed Vocational Nurse (LVN) or Licensed Psychiatric Technician (LPT) License issued by the State of California
No, I do not have a valid permanent or temporary (including an interim permit) Licensed Vocational Nurse (LVN) or Licensed Psychiatric Technician (LPT) License issued by the State of California
1B.

Please provide your License Number, your name as it appears on your License, and the expiration date of your License. If you answered "No" to question 1A., Please provide and explanation below.

2A.

How much verifiable full-time experience do you have providing psychiatric care as a Licensed Vocational Nurse (LVN) or a Licensed Psychiatric Technician (LPT) in a skilled nursing facility, psychiatric acute care setting, or related mental health setting? (Full-time experience is equivalent to 40 hours per week.)

No Experience
Some, but less than 12 Months
12 to 23 Months
24 to 35 Months
36 to 47 Months
48 to 59 Months
60 or more Months
2B.

Please provide the name of the employer(s) and the dates of employment (e.g. MM/YYYY – MM/YYYY) where you obtained your verifiable work experience as indicated in question 2A.

In addition, please list the name of (a) supervisor(s) or manager(s) who can verify the information provided as well as his or her contact information. If selected "No Experience," please type N/A.

Do not type “See Resume.”

2C.

Referring to your answers in questions 2A. and 2B., please provide a detailed description of your verifiable work experience as indicated in questions 2A. and 2B.

In your answer, include details about your specific role, your primary duties, and your responsibilities for all positions where you gained your experience. If selected "No Experience," please type N/A.

Do not type “See Resume.”

3A.

Which of the following valid American Heart Association Cardiopulmonary Resuscitation (CPR) Certificates do you possess?

Basic Life Support (BLS) for Healthcare Providers
Advanced Cardiovascular Life Supported (ACLS)
Pediatric Advanced Life Support (PALS)
None of the above
3B.

Please provide your name and the expiration date for each of the American Heart Association CPR Certificates you selected in Question 3A. If you answered "None of the above" to question 3A, please provide an explanation.

4A.

How much verifiable full-time equivalent work experience do you have as a health care provider treating patients with Co-Occurring Disorders with Substance Abuse? (Full-time experience is equivalent to 40 hours per week.)

No experience
Some, but less than 6 Months
6 to 11 Months
12 or more Months
4B.

Please provide the name of the employer(s) and the dates of employment (e.g. MM/YYYY – MM/YYYY) where you obtained your verifiable work experience as indicated in question 4A.

In addition, please list the name of (a) supervisor(s) or manager(s) who can verify the information provided as well as his or her contact information. If selected "No Experience," please type N/A.

Do not type “See Resume.”

4C.

Referring to your answers in questions 4A. and 4B., please provide a brief description of your verifiable work experience as indicated in questions 4A. and 4B. In your answer, include details about your specific role, your primary duties, and your responsibilities. If selected "No Experience," please type N/A.

Do not type “See Resume.”

5A.

How much verifiable full-time equivalent work experience do you have as a team lead, supervisor, or subject matter expert consultant, which includes developing care plans, service plans, and/or treatment plans? (Full-time experience is equivalent to 40 hours per week.)

No Experience
Some, but less than 12 Months
12 to 23 Months
24 or more Months
5B.

Please provide the name of the employer(s) and the dates of employment (e.g. MM/YYYY – MM/YYYY) where you obtained your verifiable work experience as indicated in question 5A.

In addition, please list the name of (a) supervisor(s) or manager(s) who can verify the information provided as well as his or her contact information. If selected "No Experience," please type N/A.

Do not type “See Resume.”

5C.

Referring to your answers in questions 5A. and 5B., please provide a brief description of your verifiable work experience as indicated in questions 5A. and 5B. In your answer, include details about your specific role, your primary duties, and your responsibilities. If selected "No Experience," please type N/A.

Do not type “See Resume.”

6A.

How much verifiable full-time experience do you have treating patients who have psychotic disorders (schizophrenia, schizo-affective disorder, bipolar disorder with psychotic features, etc.)? (Full-time experience is equivalent to 40 hours per week.)

No Experience
Some, but less than 6 months
6 to 11 Months
12 or more Months
6B.

Please provide the name of the employer(s) and the dates of employment (e.g. MM/YYYY – MM/YYYY) where you obtained your verifiable work experience as indicated in question 6A.

In addition, please list the name of (a) supervisor(s) or manager(s) who can verify the information provided as well as his or her contact information. If selected "No Experience," please type N/A.

Do not type “See Resume.”

6C.

Referring to your answers in questions 6A. and 6B., please provide a brief description of your verifiable work experience as indicated in questions 6A. and 6B. In your answer, include details about your specific role, your primary duties, and your responsibilities. If selected "No Experience," please type N/A.

Do not type “See Resume.”

7A.

Please select the populations you have worked with as a provider of mental health services for at least 6 months (equivalent to 1000 hours).

Young Adults (ages 18 - 25)
Geriatric
LGBT
Homeless/Indigent
None of the above
7B.

Please provide the name of the employer(s) and the dates of employment (e.g. MM/YYYY – MM/YYYY) where you obtained your verifiable work experience as indicated in question 7A.

In addition, please list the name of (a) supervisor(s) or manager(s) who can verify the information provided as well as his or her contact information. If you selected "None of the above," please type N/A.

Do not type “See Resume.”

8A.

Which of the following Certifications do you possess?

Residential Care for the Elderly (RCFE) Administrator Certification
Adult Residential Facility (ARF) Administrator Certification
None of the above
8B.

Please provide your Certification number, your name as it appears on your Certification, and the expiration date, if any, for each of the Certifications you selected in question 8A. If you selected "None of the above" in Question 8A., please type N/A.

 

CERTIFICATION: I certify that I am the author of this form and that all the information presented is true and based upon my experience. I understand that prior to an appointment I may be required to provide written verification of any of the information provided above and that I may be required by the hiring department to participate in performance test(s) during the probationary period. I further understand that any false, incomplete, or incorrect statement may result in disqualification, dismissal, or termination of employment with the City and County of San Francisco.