Official SealSan Joaquin County Human Resources Division


#0423-RH1106-AC
Supplemental Questionnaire

Last Name
First Name
1.

Licenses & Certificates:

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

If yes, please list your license number and expiration date:
2.

The following courses/certifications are all required for the position of Staff Nurse V-Clinical Inpatient for the Intensive Care Nursery. (NOTE: Copies of certifications and course completions must be attached to your employment application in order to be considered). Please check all that apply:
Yes, I have completed a Neonatal Resuscitation Program.
Yes, I have completed an ICN class.
Yes, I have completed a Preceptor class or equivalent.
Yes, I have completed the Transport Nurse class.
No, I do not possess any of the certifications noted above.
3.

Please note the education and national certification that you possess below. Education must clearly be annotated on your employment application. A copy of your National Certification must be submitted with your employment application in order to be considered. Please check all that apply:
Yes, I possess a Bachelor's of Science Degree in Nursing or related field.
Yes, I possess National Certification.
I do not possess a Bachelor's Degree in Nursing or National Certification.
4.

Do you possess at least two years of paid journey-level RN experience in an acute care hospital's Intensive Care Nursery including one year equivalent to a Staff Nurse IV in San Joaquin County?
Yes No