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#0918-RH1124-AC
Supplemental Questionnaire

Last Name
First Name

 

Please complete the following supplemental questionnaire. This questionnaire is considered an extension of your employment application and will be reviewed to help assess your qualifications. Resumes are not accepted in lieu of completing this questionnaire.
1.

Education:

Do you possess either of the following?  Check all that apply.  (Note:  If applicable, proof of National Nursing Certification in speciality area must be included with your application)
I possess a bachelor's degree in Nursing or closely related field. (Please be sure this information is clearly identified in the Education section of your application)
I possess National Certificaton as a Psychiatric-Mental Health Nurse
I do not possess a bachelor's degree in Nursing or closely related field, or National Certification.
2.

Please indicate the number of years of full-time paid experience you have as a registered nurse in a mental health facility at a level equivalent to a San Joaquin County Staff Nurse III.  Part-time paid experience may be accumulated and pro-rated to meet total experience requirements.
I possess over 2 years of RN experience in a mental health facility
I possess at least 2 years of RN experience in mental health facility.
I possess at least 1 year of RN experience in a mental health facility.
I possess less than 1 year of RN experience in a mental health facilty.
I do not possess RN experience in a mental health facilty.
3.

Please describe your full-time paid experience as a registered nurse in a mental health facility.  Include the name of your employer, employment dates, number of hours worked per week, and a description of job duties performed.
4.

License and Certificates:

Are you currently licensed as a Registered Nurse in the State of California?
Yes No
 

If Yes, please provide your license number and expiration date.
5.

Special Requirements:

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. Copies may be attached in your online application, emailed to rocastro@sjgov.org, or faxed to (209) 468-0508, ATTN: Romualdo Castro.
SJC Mental Health Department Psychiatric Nursing Assessment Certification
Preceptor Class
Other (equivalent)