Official SealSan Joaquin County Human Resources Division


#0817-RH1165-AC
Supplemental Questionnaire

Last Name
First Name

 

Please complete the following supplemental questionnaire. This questionnaire is considered an extension of your employment application and will be reviewed to help assess your qualifications. Resumes are not accepted in lieu of completing this questionnaire.


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 clearly idenified in the education section of your employment application.)

Yes No
2.

Do you currently possess a valid Nurse Practitioner license issued by the State of California?

Yes No
 

If Yes, please provide the license number and expiration date.

3.

Do you currently possess an active Registered Nurse license in the State of California?

Yes No
 

If Yes, please provide the license number and expiration date.

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 furnishing license number and expiration date.


 

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 the State of California Board of Registered Nursing furnishing license within one (1) year of employment.


5.

Please list any speciality nursing certifications you may possess, and/or specialty training courses you may have completed.

6.

Please provide a deatiled description of your clinical nursing experience.  State the name of your employer, employment dates, job title, number of hours worked per week, and the specific job duties performed.  Include the settings in which you have worked and the volume of patients seen on a daily basis.  Experience in a psychiatric/mental health setting is desirable.