Official SealSan Joaquin County Human Resources Division


#0523-RH1162-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.

The following Licenses/Certifications are all required to qualify for this position: RN License, Nurse Practitioner Certification and current Furnishing License all with the CA Board of Registered Nursing. 

Do you possess all of these licenses?

If Yes, please be sure the Licenses section of your application is completed in detail. 

Yes No
3.

Do you possess a Bachelor's Degree in Nursing? If yes, please be sure to complete the education portion of the application in detail. 

Yes No
4.

Do you possess National Nursing Certification? If yes, please attach to your application when prompted to attach a resume.

Yes No
5.

How many years of experience as a Nurse Practitioner do you possess?

Less than 2 years
2 to 4 years
5 years or more
6.

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
7.

San Joaquin General Hospital is a 24/7 operating facility. Incumbents employed with San Joaquin General Hospital must have the ability to work rotating shifts which include nights, weekends and holidays. Please indicate if you acknowledge and accept this requirement.

Yes, I acknowledge and accept that the position may require working rotating shifts, including nights, weekends, and holidays.
No, I'm unable to work rotating shifts which includes nights, weekends, and holidays.