Official SealSan Joaquin County Human Resources Division

Supplemental Questionnaire

Last Name
First Name

Please provide your RN license number.


Please select below the amount of paid experience that you possess as a registered nurse in an acute care or mental health facility: 

Zero to less than 6 months
6 months to 1 year
1 to 3 years
More than 3 years

Provide the following information below for each employer where you were employed as a registered nurse in an acute care or mental health facility. Include this information also in the Employment section of your application.

  • Name of the facility
  • Starting and ending dates of employment
  • Number of hours worked per week
  • Nursing unit assigned


Please note that when selecting the inpatient units of interest, vacancies in the units may not be currently available although effort is made to hire candidates into their primary department of interest. Shifts may include working nights, weekends, and holidays.


Please select from the following list of inpatient units for which you are interested in being referred for hiring consideration:

Cardiac Cath Lab / EKG
Emergency Department
Float Pool Unit*
GI / Short Stay Surgery
Intensive Care Nursery (NICU)
Intensive Care Unit
Labor-Delivery-Recovery-Post Partum
Medical-Surgical Unit*
Medical Guarded Unit (MGU)*
Post-Anesthesia Care Unit (PACU)
Progressive Care Unit (PCU)
All of the above

*Note: Candidates hired in the following units must successfully pass a California Department of Corrections and Rehabilitation (CDCR) background investigation and must maintain their clearance for continued employment: Float Pool, Medical-Surgical, Medical Guarded Unit, and Surgery.

Please indicate that you have read and understand this condition of employment for the units identified.

I understand and agree with this condition of employment.
I am not interested in being referred to the listed departments.

**Note: If Post Anesthesia Care Unit (PACU) or Surgery has been selected as a department of interest, candidates must be able to report to work within 30 minutes of call back.

I acknowledge the term and condition of employment listed above.
I am not interested in being referred to PACU or Surgery units.


Please select from the list below for which you currently possess active certifications (check all that apply):

CCRN (or other National Certification)
EKG or course completion
None of the above

     If "other" was selected, please provide name of the certificate here:


As a 24-7 facility, San Joaquin General Hospital employees may be asked to be available to work any shift.

Listed below are various examples of shifts. Check all shifts for which you are available to work.

Days: 7:00AM - 3:00PM
PMs: 3:00PM - 11:30PM
Nights: 10:30PM - 7:00AM