San Joaquin County Human Resources Division
#0218-RH1104-TM
Supplemental Questionnaire
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| First Name |
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Please attach applicable licenses and certificates to the online employment application. Failing to provide a copy of your licenses and certificates may result in a failure to move forward in the selection and hiring process. All relevant RN experience should be included in the application. |
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1 Education: Do you possess a Bachelor's Degree in Nursing or closely related field. (If yes, please be sure to clearly indicate the status of your degree in the "education" portion of your employment application.) |
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2 License: Provide your current RN License Number so that it can be source verified with the State of California Board of Registered Nursing. If you do not possess a valid or current RN License, please note "N/A": |
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3 Please select from the following list of inpatient units for which you are interested in being referred for hiring consideration: |
| Emergency Department |
| Float Pool |
| Hemodialysis |
| Intensive Care Nursery (ICN) |
| Intensive Care Unit (ICU) |
| Labor and Delivery |
| Medical-Surgical Unit |
| Medical Guarded Unit (MGU) |
| Operating Room (OR) (must be able to report within 30 minutes of call) |
| Pediatrics / Post-Partum |
| Post-Anesthesia Care Unit (PACU) |
| Progressive Care Unit (PCU) |
| Other |
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3a If "other" was selected, please identify the department below. |
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The following section will be utilized to determine if you possess the license and/or certifications required to qualify as a Staff Nurse IV for a specific inpatient unit. Please check all that apply. Copies may be attached to your online application where resume attachment is offered, e-mailed to jripp@sjgh.org, or faxed Attn: Joanne to (209) 468-6271. |
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4 Please indicate if you possess any of the following certificates: |
| ACLS |
| BLS |
| CPR |
| PALS |
| Preceptor course or Nursing Trainer certificate |
| Advanced Fetal Heart Monitoring course certificate |
| Chemotherapy certification |
| Critical Care course certificate |
| ED Essentials Course certificate or equivalent |
| Fetal Heart Monitoring course certificate |
| Fluid and Electrolyte course certificate |
| Hemodynamic Monitoring certificate |
| ICN course certificate |
| MSE Triage course certificate |
| MICN-Code 3 Clearance |
| Neonatal Resuscitation Program (NRP) |
| PICC (Peripherally Inserted Central IV Catheters) certificate |
| Renal Failure course |
| National certifications (CEN, CCRN, CNN, CDN, CPAN, CNOR, PCCN) |
| Other |
| None of the above |
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5 If other was selected, identify the licenses and/or certificates. |
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6 Note: Candidates hired in the following units must successfully pass a California Department of Corrections and Rehabilitation (CDCR) background investigation and must maintain their clearance for continued employment: Medical-Surgical, Medical Guarded Unit, Float Pool. Please indicate that you have read and understand this condition of employment for the units identified. |
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I understand and agree with this condition of employment. |
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I am not interested in being referred to the listed departments. |