Official SealSan Joaquin County Human Resources Division


#0518-RH1106-AC
Supplemental Questionnaire

Last Name
First Name
1

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

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.)
Yes No
3

Certifications:

Please indicate if you possess the following certifications:

Note: Copies of the all certificates must be submitted with the application when prompted to add a resume, or sent to msneed@sjgh.org, or faxed to (209) 468-6271.
Neonatal Intensive Care Nursing national certification
Neonatal Resuscitation Program (NRP)
ICN class
Transport Nurse
Preceptor Class or equivalent
I do not possess any of the certifications listed.
I possess all of the certifications listed.
4

I possess the following number of years of licensed Registered Nurse experience in an acute care hospital Intensive Care Nursery or Neonatal Intensive Care Unit. (Employer, Dates of Employment, Hours Per Week Worked, and nursing duties must clearly be defined on the "experience" portion of your employment application and/or resume):

Note: Experience is considered at the full-time (40 hours per week) equivalent.
1 year of paid RN experience
2-4 years of paid RN experience
5 or more years of paid RN experience
I possess less than 1 year of paid RN experience
I do not possess any paid RN experience in this type of Inpatient Unit