Official SealSan Joaquin County Human Resources Division


#0618-RH1106-A2
Supplemental Questionnaire

Last Name
First Name

 

LICENSES & CERTIFICATES

Note: Copies of licenses and certificates must be submitted with a completed employment application. They may be submitted by attaching them to the employment application when prompted for a resume, sent via email to msneed@sjgh.org, or by fax to (209) 468-6271.
1

Please indicate if you possess or have completed the following. Please select all that apply.
Fetal Heart Monitoring class
Advanced Fetal Heart Monitoring class
Neonatal Resuscitation class
Preceptor class or equivalent (adult educator/trainer equivalent)
National certification
Bachelor's degree in Nursing (BSN) or related field. (This information should be clearly identified in the Education portion of the application)
I have not completed or possess any of the above.
 

If you indicated that you possess a national certification, please identify the type of certification and the certifying agency below.
2

This position requires a license as a Registered Nurse issued by the State of California Board of Registered Nursing. Provide your license number and expiration date.
3

EXPERIENCE

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

If yes, describe the specific journey-level FMC duties performed. Include the following:

  • Employer
  • Dates of Employment
  • Number of hours worked per week
4

Please describe your experience as a charge nurse or nursing supervisor. Include in your response the number of staff supervised and how you monitored their performance.