Official SealSan Joaquin County Human Resources Division


#0618-RH1105-01
Supplemental Questionnaire

Last Name
First Name
1

Licenses & Certifications

Do you possess a current active license as a registered nurse from the California Board of Registered Nurses (CA BRN)?
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 attach to your application when prompted for a resume, send to msneed@sjgh.org, or fax to 209-468-6271.
2

Please indicate the education completed and/or the national certification you possess below. Check all that apply.  Copies of certificates must be submitted with the employment application.
Bachelor's degree in Nursing or related field
CNOR certification
Hemodynamic Monitoring class
Preceptor class or equivalent
ACLS
None of the above
3

Do you possess at least two years of full-time (40 hours per week) paid RN experience in an acute care hospital OR?
Yes No
 

If you responded yes, please provide the specific journey-level RN duties performed in the acute care hospital OR.
4

Please describe your experience as it specifically relates to being a clinical educator. Include in your answer the number of staff you precepted, your precepting approaches, and how you monitored the success of the staff you mentored.
5

Please describe your experience in working with nursing or healthcare administration on developing the clinical skills of nursing staff in a perioperative environment.
6

Please describe your experience and understanding of the circulating nurse's role in an Operating Room. Include in your answer what key elements should be present when educating new nurses on this key role.