Official SealSan Joaquin County Human Resources Division


#1122-RH1124-FL
Supplemental Questionnaire

Last Name
First Name
1.

Please indicate which Staff Nurse level you would like to be evaluated for:
Staff Nurse III
Staff Nurse IV
Both
2.

Do you have at least 6 months of RN experience in an acute care hospital or mental health facility?
Yes No
3.

Do you have at least one year of progressively responsible experience as a registered nurse? 
Yes No
4.

Do you have at least two years of RN experience in Ambulatory Care Services?
Yes No

 

If yes, please ensure this is CLEARLY demonstrated in the Employment Experience section of the application. 
5.

Do you have a Bachelor's Degree in Nursing or a related field?
Yes No

 

Please ensure this is CLEARLY indicated in the Education section of your application.
6.

Are you currently registered as a nurse in the State of California?
Yes No

 

Please ensure this is CLEARLY indicated in the Professional Licenses, Certifications, or Registrations section of your application. 
7.

Please indicate which of the following certifications you possess (please attach copies with your application):
ACLS
EKG
PALS
Preceptor
8.

By checking this box, I understand that:  (1) Successful completion of a San Joaquin General Hospital in-service or comparable training program in nursing preceptorships may be required prior to completion of the probationary period and periodically thereafter.  (2) Possession of a San Joaquin County Mobile Intensive Care Nurse (MICN) certificate, Advanced Cardiac Life Support (ACLS) certificate, completion of an approved ICU/CCU training course, or other approved training or experience may be required for assignment or continued assignment to specialized nursing units.