Official SealSan Joaquin County Human Resources Division


#0918-RH1105-AC
Supplemental Questionnaire

Last Name
First Name

 

Copies of all licenses and certifications must be submitted with the completed employment application. Failing to provide the required documents may result in a failure to move forward in the selection and hiring process. Copies of the licenses and certifications may be submitted when prompted to upload a resume, emailed to msneed@sjgh.org, or faxed to (209) 468-6271. All relevant RN experience should be included in the application.

All offers of employment are conditional upon successfully passing a pre-employment drug screen and an arduous physical.
1

Please provide your RN license number which will be source verified.
2

The following courses/certifications are required to qualify for the position of Staff Nurse V-Inpatient Clinical for the Emergency Department. Please check all that apply.
ED Essentials Course or equivalent
MSE Triage Course
MICN-Code 3 Clearance (must be obtained within 6-12 months of hire or promotion to the Staff Nurse V
ACLS
PALS
Preceptor course or equivalent
I do not possess any of the certifications listed.
3

Please indicate if you possess the following education and/or special certifications.
Bachelor's of Science in Nursing or related field (this should be clearly identified in the Education portion of the application)
CEN or CCRN
TNCC or ENPC
I do not possess or have not completed any of the above.
4

Please provide a brief description of your RN experience in an acute care hospital Emergency Department.  Include the following:

  1. Acute Care Hospital
  2. Dates of employment (from/to)
  3. Number of hours worked per week
  4. Specific nursing duties and responsibilities
  5. Charge nurse experience
  6. Experience precepting staff

If your experience includes working as a traveler/registry, clearly identify each acute care hospital for which you were assigned.