Official SealSan Joaquin County Human Resources Division


#0122-RH2501-TM
Supplemental Questionnaire

Last Name
First Name
1

Some positions may be assigned to the PHF (Psychiatric Health Facility), a 24-hour inpatient facility, or other programs which may require working rotating shifts that include nights and weekends.

If these positions are available, would you be interested in a referral?
Yes No
2

The position requires completion of an accredited training program for Psychiatric Technicians for entrance to testing.

If you have completed a program, provide the name of the institution or college where you completed the program, the date you completed the program, and the name of the program.

Note:  Prior to employment, must possess a valid license as a Psychiatric Technician issued by the California Board of Vocational Nurse and Psychiaric Technician Examiners.
3
Do you have a valid Psychiatric Technician License issued by the State of California?
Yes No
 

If you answered yes to question #3, provide your license number and expiration date.