Official SealSan Joaquin County Human Resources Division

Supplemental Questionnaire

Last Name
First Name

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

Licenses & Certificates:

Are you currently licensed as a registered nurse in the State of California?

Yes No

If yes, please list the license number and expiration date.


Do you possess a Bachelor’s Degree in Nursing? (Please Note: If yes, be sure to clearly identify your degree either on the education portion of your employment application or resume as it will be source verified).


Yes No

Do you possess nursing National Certification?(A copy of your certification must be submitted with employment application in order to be considered)

Yes No

Licenses and Certificates:

In order to qualify for this position you must have successfully completed a Fetal Heart Monitoring Class, Advanced Fetal Heart Monitoring Class, Neonatal Resuscitation Class, and Preceptor Class. (Please note that 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 Fetal Heart Monitoring Class
Yes, I have completed an approved Advanced Fetal Heart Monitoring Class
Yes, I have completed an approved Neonatal Resuscitation Class
Yes, I have completed an approved Preceptor Class (or adult educator/trainer equivalent)
I have not completed any of the above mentioned courses/certification

Do you possess two (2) years of registered nurse experience in an acute care Family Maternity Center?

Yes No

If yes, please describe in detail your journey-level FMC duties below. Please include: Name of Employer, Job Title, dates of employment and hours per week worked.


Please describe your experience as a Charge Nurse or Nursing Supervisor.


Please describe your experience in working with nursing or healthcare administration on developing the performance skills of nursing staff in a labor & delivery environment.


Please describe your experience and understanding of the circulating nurse's role in an OB Operating Room. Include in your answer what key elements you would assess when supervising new nurses in this role.