Official SealSan Joaquin County Human Resources Division


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Supplemental Questionnaire

Last Name
First Name

 

Please complete the following supplemental questions.  This is an important part of your application package that will allow Human Resources to thoroughly assess and evaluate your qualifications for the position of Staff Nurse IV, Inpatient per diem, for the Sexual Assault Forensic Examiner (SAFE) Program.


1

Pattern I:

Do you have two (2) years of progressively responsible experience as a registered nurse in an acute care setting?

Yes No
 

If yes, please describe the duties you performed, your title, the name of the acute care institution you worked for, dates of employment and hours worked per week:

2

Or, Pattern II:

Do you have a Bachelor's degree in Nursing, Health Science, or closely related field?  (If yes, please be sure that information is clearly noted on your employment application in the education section).

Yes No
 
Do you have one (1) year of progressively responsible experience as a registered nurse in an acute care hospital?
Yes No
 

If yes, please describe the duties performed in the acute care hospital.  Please include the name of the acute care hospital you worked for, your title, dates of employment, and hours worked per week.

3

License and Certificates:

Please list your current registration information as a nurse in the State of California.  Please include your license number and expiration date.

 

This position will be required to serve as a Sexual Assault Forensics Examiner and participate on the SAFE Team.

Have you completed the Adult and Pediatric Sexual Assault Training provided by the California Clinic Forensic Medical Training Center?  Proof of completion of training must be submitted with application.

Yes No