Superior Court of California County of Santa Clara 191 North First Street San José, California 95113 (408) 882-2700 HALL OF JUSTICE FORENSIC EVALUATOR PANEL APPLICATION Please include an updated resumé and redacted sample reports in addition to this application. If you are applying for both the Adult and Juvenile Panels, submit two redacted sample reports (one Adult evaluation and one Juvenile evaluation). Otherwise, submit one redacted sample report for either Adult or Juvenile. Do your best to thoroughly complete all sections of this application. If you need additional room, please attach a separate sheet of paper. APPLICATION TYPE (choose one): 1. CONTACT INFORMATION Name: Address: Phone: Email: 2. EDUCATION AND CREDENTIALS Degree (choose one): Year Degree Received: Institution Degree Received From: California License Number: Date of Issuance: Fax: Yes No Are there any suspensions on your license? If yes, please attach an explanation of the circumstances surrounding the suspension. If M.D. Location of Psychiatric Residency: Date of Certification: Number of hours of direct clinical oversight for adults: Number of hours of direct clinical oversight for youth (10-18): Describe any formal education and/or training on Forensic Evaluation: If applying for the Juvenile Panel, please describe any formal education and/or training on adolescent development: CR-6081 REV 05/03/12 Forensic Evaluator Panel Application Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 3. EXPERIENCE IN FORENSIC EVALUATION Have you ever served on an evaluation panel in another jurisdiction? If yes, which jurisdictions? Are you still active on this panel? Yes No If no, please describe why you are no longer on the panel: Yes No Please check the case types with which you have performed evaluation and prepared reports. If yes, provide the total number of reports submitted: A. Penal Code 1027 (sanity at the time of the offense)? B. Penal Code 1368 & 1369 (current mental competence)? C. Penal Code 1017 (assistance to defense counsel in mental competence question)? D. Penal Code 1370 (issues involving developmental disability)? E. Welfare and Institutions Code 3051 (potential narcotics addiction)? F. Welfare and Institutions Code 5000 & 6500 (proceedings under the LPS Act and developmental disability)? G. Welfare and Institutions Code 6600 (sexually violent predators)? H. Penal Code 288.1 (mental condition of persons convicted of lewd acts on a child under the age of 14)? I. Juvenile Competency Reports Yes Number of reports: Yes Number of reports: Yes Number of reports: Yes Number of reports: Yes Number of reports: Yes Number of reports: No No No No No No Yes Number of reports: Yes Number of reports: No No Yes Number of reports: No 4. CLINIC ROTATION The Interview Clinic is held at the Courthouse on Monday afternoons. Evaluators opting to participate in the Clinic will be scheduled for Clinic evaluations on a rotating basis. Would you like to be placed on the rotation for Clinic Interviews? Yes No CR-6081 REV 05/03/12 Forensic Evaluator Panel Application Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 5. SIGNATURE I have read and understand the Forensic Evaluator Manual, and familiarized myself with the applicable statutes and governing case law interpreting the standards set forth in the applicable statutes. I agree to comply with all requirements outlined in the Forensic Evaluator Manual. I hereby declare under penalty of perjury that to the best of my knowledge the foregoing information is true. Signature: Print Name: Date: CR-6081 REV 05/03/12 Forensic Evaluator Panel Application Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com