Official SealSan Joaquin County Human Resources Division


#1022-RH1104-01
Supplemental Questionnaire

Last Name
First Name
 

Education:

Do you possess either of the following?  Check all that apply.  (Note:  If applicable, proof of National Nursing Certification in speciality area must be included with your application)

I possess a bachelor's degree in Nursing or closely related field. (Please be sure this information is clearly identified in the Education section of your application)
I possess National Certificaton as a Psychiatric-Mental Health Nurse
I do not possess a bachelor's degree in Nursing or closely related field, or National Certification.
 

Education

This position requires at least one year of progressively responsible experience as a registered nurse in an mental health hospital at a level equivalent to a San Joaquin County Staff Nurse III.

Please describe your relevant work experience in the space provided below.  Include employer name, job title, dates of employment, and job duties in your description.

 

License and Certificates:

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

Yes No
 

If Yes, please provide your license number and expiration date.

 

This position requires a Mobile Intensive Care Nurse (MICN) certificate, Advanced Cardiac Life Support (ACLS) certificate or state, national, or other types of certification in area of specialty; please provide the following for each certification:

  • Type of certification
  • Certification number (if applicable)
  • Expiration date
 

Special Requirements:

The following section will be utilized to determine if you possess the license and/or certifications required to qualify as a Staff Nurse IV for a specific inpatient unit. Copies may be attached in your online application, emailed to rocastro@sjgov.org, or faxed to (209) 468-0508, ATTN: Romualdo Castro.

SJC Mental Health Department Psychiatric Nursing Assessment Certification
Preceptor Class
Other (equivalent)
 

Please attach copies of license and/or certifications required to qualify as a Staff Nurse IV for a specific inpatient unit. Copies may be attached in your online application, emailed to manunez@sjov.org, or faxed to (209)468-0508, ATTN: Mayra Nunez. 

  • SJC Mental Health Department Psychiatric Nursing Assessment Certification 
  • Preceptor Class
  • Other (equivalent) 

If selected "Other" please specify below: