Official SealSan Joaquin County Human Resources Division


#0923-RH2060-AC
Supplemental Questionnaire

Last Name
First Name
1.

Education:

Have you completed a Hemodialysis Training Program that has been approved by the State of California? 
Yes No
2

Professional Certification:

Are you currently Certified as a Hemodialysis Technician (CHT) by the State of California?
Yes No
 

I understand that I must attach a copy of my certification. 
 

If no, please indicate if you have the ability to obtainCalifornia certification as a Hemodialysis Technician within six (6) months after training program has been completed.

Also indicate:

  • The date you completed your training program and
  • The date you applied with the State of California to become certifed as a Hemodialysis Technician.