Official SealSan Joaquin County Human Resources Division


#0622-RH1104-A1
Supplemental Questionnaire

Last Name
First Name
1

Do you possess a Bachelor's degree in Nursing or a closely related field?

Please ensure that the information is clearly identified in the Education section of the employment application.
Yes No
2

In order to be eligible for the Staff Nurse IV in the Emergency Department, the following classes, courses, or certifications must have been successfully completed.  Please check all that apply:

Note: Please submit copies of all certifications with the completed employment application, or send via email to alhandelman@sjgov.org, or fax to (209) 468-0508.
ACLS
ED Essentials or equivalent
MICN-Code 3 clearance
MSE Triage
PALS
Preceptor class or equivalent
CEN or CCRN
TNCC or ENPC
None of the above
3

Please identify the number of years of full-time (40 hours per week) paid RN experience in an acute care hospital's ER department you possess.
Less than 1 year of RN experience in an acute care hospital's ER
1-2 years of RN experience in an acute care hospital's ER
More than 2 years of RN experience in an acute care hospital's ER
I do not possess any RN experience in an acute care hospital's ER
4

Please provide your RN license number below: