Official SealSan Joaquin County Human Resources Division

Supplemental Questionnaire

Last Name
First Name

Licenses and Certificates:

In order to qualify to work in the PACU, you must have successfully completed the Hemodynamic Monitoring Class, PALS, Preceptor Class and ACLS certification. NOTE: Proof of completion must be submitted with your employment application in order to be considered. Please check all that apply below:

Yes, I have completed an approved Hemodynamic Monitoring Class
Yes, I have completed an approved Preceptor Class (or adult training equivalent)
Yes, I have completed an approved PALS Class
Yes, I currently have ACLS Certification
I have not completed any of the above mentioned courses/certification

Are you currently licensed as a Registered Nurse with the State of California?

Yes No

If yes, please provide your license number below:


Pattern I:

Do you possess a Bachelor's Degree in Nursing?

Yes No

If yes, please list the name of the college and/or university you obtained your BSN from:


Pattern II:

Do you possess National Certification? (Please Note, if yes, you must provide proof of certification with your employment application in order to be considered)

Yes No


Do you possess at least two (2) years of paid Registered Nurse experience in a Post Anesthesia Care Unit (PACU), including one year equivalent to a San Joaquin County Staff Nurse IV?

Yes No

If yes, please provide a detailed description of the RN duties you performed while working in a PACU. Please include: Name of Employer, Job Title, dates of employment and hours per week worked and whether or not you supervised or trained staff in this type of unit or have created policies and/or procedures for a perioperative environment.


San Joaquin General Hospital is a 24/7 running facility. Employees are expected to be open to working rotating shifts that will include nights, weekends and holidays. Are you available to work in a position that has these requirements?

Yes No