Official SealSan Joaquin County Human Resources Division


#0422-RH1106-PC
Supplemental Questionnaire

Last Name
First Name
1.

Are you currently registered as a nurse in the State of California?
Yes No
 

If yes, please list your license number and expiration date:
2.

Education:

Do you possess a Bachelor's degree? (Note: If yes, please make sure it is clearly identified on your employment application under education or resume).
Yes No
 

If yes, please list

  • Type of degree (i.e. bachelors, masters, etc.)
  • Major course of study
  • Name of college or university
3.

Do you possess at least three years of experience as a journey level registered nurse in an acute care or mental health facility? (Note: One year of the required experience may be substituted with a qualifying Bachelor's Degree)
Yes No
 

If yes, please identify the items below, and include any experience serving as a house supervisor, charge nurse, a preceptor to new nurses or in a leadership capacity:

  • Name of employer, and the nursing unit that you worked on
  • Starting & ending dates of employment
  • Job title & responsibilities
4.

Please indicate if you possess any of the following certificates (check all that apply):
BLS
ACLS
PALS
National Certification (CCRN, etc.)
Preceptor Training Certificate
Critical Care Certificate
Other
 

If "Other", please list certificate: