Official SealSan Joaquin County Human Resources Division


#0423-RH1161-TM
Supplemental Questionnaire

Last Name
First Name
1.
Have you completed an approved Nurse Practitioner training program at an accredited college or university or certified program? (If Yes, please be sure the information is noted clearly on your employment application and/or resume as it will be source verified)
Yes No
2.
Do you currently posses a valid Nurse Practitioner license issued by the State of California?
Yes No
 

If yes, please provide the license number:
3.

Do you currently possess an active registered nurse license in the State of California?
Yes No
 

If yes, please provide the license number.
4.
Do you currently possess a valid furnishing license through the State of California Board of Registered Nursing?
Yes No
 
If yes, please provide the number and expiration date. (Please Note: If you do not currently possess a furnishing license through the State of California, Board of Registered Nursing, you must have the ability to obtain your Registered Nursing furnishing license within one (1) year of employment.)
5.

Do you acknowledge and accept the following:

In order to practice at San Joaquin General Hospital, you must be credentialed and  granted privileges through the San Joaquin General Hospital Committee on Interdisciplinary Practice (CIDP) within ninety (90) days of appointment and in accordance with medical staff bylaws and state regulations.  New employees may be granted temporary privileges by the Medical Director or designee, pending Committee Interdisciplinary Practice approval. Eligibles may be certified only to job vacancies in the area of specialization in which they posses specialized education and certification.  Additionally, the successful completion of approved nursing training programs, possession of specific nursing experience or the possession of specified professional certificates may be required depending on the nature of the area of assignment.
Yes No