Official SealSan Joaquin County Human Resources Division

Supplemental Questionnaire

Last Name
First Name


This supplemental questionnaire must be submitted with your employment application. Failure to complete the application or supplemental questionnaire in its entirety may delay the application process. 


Please check the box(es) for the Staff Nurse Level(s) you would like to be considered for.

Staff Nurse I (RN License Only)
Staff Nurse II (Current/Former County Employee)
Staff Nurse III (RN License AND 6 Months Experience OR BSN/MSN)

Please indicate if you possess one of the following:

State of California Registered Nursing (RN) license
State of California Interim Permit as issued by the Board of Registered Nursing (BRN)
None of the above


Have you been employed with San Joaquin County Department of Health Care Services or San Joaquin General Hospital as a Student Nursing Assistant, Nursing Assistant or Licensed Vocational Nurse during enrollment of a registered nurse training program?

Yes No

If yes, please list your title, dates of employment and agency you worked for.


Do you possess 6 months paid experience as a registered nurse in an acute care or mental health facility? Please note employment with Skilled Nursing Facilities are not considered acute care.

If you answered Yes, please make sure to provide detailed information in the Employment section of your application. 

Yes No

A Bachelor's Degree in Nursing (BSN) or Master's Degree in Nursing (MSN) may substitute for the required 6 months of registered nurse experience for the Staff Nurse III.  To use this substitution pattern, please identify the college or university attended, and the degree awarded:


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

If "other" was selected, please identify the Inpatient Department(s) below:


*As a condition of employment, candidates must successfully pass a California Department of Corrections (CDCR) background investigation conducted by the California Department of Corrections and Rehabilitation. Please check the below box to acknowledge you understand the above terms.

Yes, I acknowledge and understand the above terms.

**Note: If Surgery-Recovery has been selected as a unit of interest, positions in this unit must be able to report to work within 30 minutes of call back.

Yes, I acknowledge the term and condition of employment listed above.
I am not interested in being referred to the Surgery-Recovery unit.


This recruitment will be utilized to fill full-time, part-time, and per diem positions. Please ensure to mark the first page of your employment application with your desired employment status interest (select all that are applicable).  See example screen shot below:

Type of employment you are willing to accept: Full-Time Part-Time Temporary Contract Per Diem (Health Care Services Only)