Official SealSan Joaquin County Human Resources Division


#0523-RH1104-AC
Supplemental Questionnaire

Last Name
First Name
1.

License:

Are you currently a registered nurse in the State of California?
Yes No
2.

Please indicate the number of years of full-time, progressively responsible, journey level, acute care registered nursing experience you possess.

(Ensure that this experience matches what you have included in the employment experience on your application)
Less than 1 year
1 year
2 years
3 or more years
3.

Do you possess a Bachelor's degree in Nursing (BSN)? (Please note: If yes, clearly identify your degree under the Education section of the employment application.)
Yes No
4.

Please check the box(es) for all certifications that you currently possess. Please upload copies of all certifications when prompted to upload a resume.
National Nursing Certification
Advanced Cardiac Life Support (ACLS)
MICN-Code 3 Clearance
Trauma Nurse Core Curriculum
Emergency Nurse Pediatric Course
Trauma Care After Resuscitation Course
Transport Nurse Advanced Trauma Course
Preceptor
Critical Care Class
Pediatric Advanced Life Support (PALS)
EKG Class
Physical Medicine and Rehabilitation (PM&R)
ED Essentials
ICN Class
MSE Triage