(rev 11/2016)CalHR 884
Read the following instructions carefully before completing this Criminal Record Supplemental
Questionnaire. If the Examination Bulletin requires this Criminal Record Supplemental Questionnaire to
be submitted with your application, you must complete all sections and answer the required questions
completely and accurately.
Applicant Identification Number (Easy ID) – Enter the required tracking information on the Criminal
Record Supplemental Questionnaire: the first three letters of your last name at birth, the month and day
of your birth and the last four digits of your Social Security Number.
Easy ID – The Easy ID represents a compilation of the data collected from the Applicant Identification
Number section. If you are unable to determine your Easy ID, please leave it blank.
Exam for which you are applying – Fill in the title(s) of the examination for which you are applying as it
is listed on the Examination Bulletin.
Questions 1 & 2 – Answer these questions only if required on the Examination Bulletin.
Explanations – Use this section to explain the details of any response that requires additional
information. Be through and attach additional sheet(s) if necessary.
Signature – Your signature and the date signed is required. If the Criminal Record Supplemental
Questionnaire is not signed, it may be rejected.
California Department of Human Resources Privacy Notice on Information Collection
This notice is provided pursuant to the Information Practices Act of 1977.
The California Department of Human Resources (CalHR), Selections Division, is requesting the
information specified on this form pursuant to Government Code 18934 and the Privacy Act of 1974.
The information collected will be used for state civil service employment and will/may be disclosed to
other State Departments and third party vendors for business purposes only as required by law.
Individuals should not provide personal information that is not requested or required.
The submission of all information requested is mandatory unless otherwise noted. If you fail to provide
the information requested, CalHR will not be able to determine your eligibility for state civil service
employment and contact you as necessary.
The information collected by CalHR is subject to the limitations in the Information Practices Act of 1977
and state policy. For more information on how we care for your personal information, please read our
Access to Your Information
The CalHR Privacy Officer is responsible for maintaining collected records. You have a right to access
records containing your personal information we maintain. To request access, contact:
CalHR Privacy Officer
1515 S Street, 500N
Sacramento, CA 95811