Official SealSan Joaquin County Human Resources Division


#0822-RH1813-01
Supplemental Questionnaire

Last Name
First Name
1.

Do you currently possess an active Registered Nurse license in the State of California?

Yes No
 

If you answered Yes, please provide your Registered Nurse license number and expiration date.

2.

Do you possess a valid registration as a Public Health Nurse in the state of California?

Yes No
 

If you answered Yes, please provide your Public Health Nurse license number and expiration date.

3.

Please describe your three years of full-time, paid, post-bachelor's degree nursing experience which included two years of full-time, paid, community-based nursing in a community health, public school, county public health, or comparable setting that included work in areas such as communicable disease response/prevention, health education, public health, emergency planning, or community-based nursing case management.  Include the name of employer, dates of employment, job title, a description of responsibilities and duties performed, and the number of hours worked per week.


*

If required by the nature of the assignment, this position also requires possession of a valid California Driver License.