Official SealSan Joaquin County Human Resources Division


#0817-RH1104-AC
Supplemental Questionnaire

Last Name
First Name
1

Do you currently possess a valid Registered Nurse license with the Board of Registered Nursing?
Yes No
 

Please provide your RN license number which will be source verified.

A copy of your RN license must be submitted with your completed employment application. Please send to msneed@sjgh.org or by fax to 209-468-6271.
2

Possession of 1) Current Advance Cardiac Life Support (ACLS) and BLS certification, 2) A certificate of completion of Trauma Nurse Core Curriculum (TNCC) and Pediatric Life Support (PALS) or Emergency Nurse Pediatric Course (ENPC) is required. Check All certification(s) you possess below:

(Please note: Copies of all certifications must be submitted with employment application in order to be considered.)
I possess ACLS certification.
I possess BLS certification.
I possess TNCC certification.
I possess PALS certification.
I possess ENPC certification.
I do not possess any of these certifications.
3

Do you possess a Bachelor’s Degree in Nursing, Health Science, or closely related field? (If yes, please be sure it is clearly noted on your employment application in the education portion or on your resume)  
Yes No
4

Do you possess progressively responsible advanced critical care registered nursing experience in a high volume (a minimum of 2500 ER visits per month) Emergency Department, Intensive Care Unit, PACU (Recovery Room), or as a Flight Nurse or Trauma Nurse Clinician?
Yes No
 

If yes, please describe your nursing duties in these areas. Include in your answer: Job title, employer, dates of employment, hours per week worked, and the specific unit(s) you worked in.
5

Special Requirement: This position requires you successfully complete the Emergency Medical Services Agency (SJEMSA), Mobile Intensive Care Nurse (MICN) and Trauma Care after Resuscitation Course (TCAR) or Transport Nurse Advanced Trauma Course (TNATC) within one year from date of employment with San Joaquin General Hospital.

Do you acknowledge and accept this as a condition of continued employment with San Joaquin General Hospital?
Yes No
6

Do you currently possess the following? (Check All that apply):
I currently possess SJEMSA certification.
I currently possess MICN certification.
I currently possess TCAR certification.
I currently possess TNATC certification.
I do not currently possess these certifications.