Official SealSan Joaquin County Human Resources Division


#0918-RH1161-AC
Supplemental Questionnaire

Last Name
First Name

 

Please note that copies of the Nurse Practitioner and/or Nurse Practitioner Furnishing certificates must be submitted with the completed employment application. The copies may be submitted when prompted for a resume, faxed to 209-468-6271, or emailed to msneed@sjgh.org.

As a reminder, in order to practice at San Joaquin General Hospital (SJGH), candidates must be credentialed and granted privileges through the SJGH Committee on Interdisciplinary Practice (CIDP) within 90 days of appointment and in accordance with medical staff bylaws and state regulations. New employees may be granted temporary privileges by the Medical Director or designee, pending CIDP approval.


1

Have you completed an approved Nurse Practitioner training program at an accredited college or university or certified program? (If Yes, please be sure the information is noted clearly on your employment application and/or resume)

Yes No
1a

If you responded yes, please provide the following information:

  1. Nurse Practitioner program completed
  2. Specialty training courses completed
2

Please indicate if you possess the following:

Bachelor's degree in Nursing or related field
National certification in a speciality area
Nurse Practitioner license issued by the California Board of Registered Nurses
Nurse Practitioner Furnishing license issued by the California Board of Registered Nurses
All of the above
None of the above
2a

Please provide the license/certificate number of the following so that it can be sourced verified by Human Resources. If you do not possess the license, please note "N/A":

  1. California RN license number
  2. Nurse Practitioner number
  3. Nurse Practitioner Furnishing number
3

Please indicate the number of years of full-time (40 hours per week) paid experience you possess as a nurse practitioner.

less than one year
1-2 years
2-3 years
3-4 years
4-5 years
more than 5 years
I do not possess any full-time paid nurse practitioner experience.
3a

Please describe your experience as a nurse practitioner.  Include in your response the following:

  1. Employer
  2. Dates of employment
  3. Number of hours worked per week
  4. Specific duties performed

If none, note "n/a".

4

Please indicate if you possess specialty certificates of training.  If none, please note "n/a".

 

San Joaquin General Hospital is a 24/7 operating facility. Incumbents employed with San Joaquin General Hospital must have the ability to work rotating shifts which include nights, weekends and holidays. Please indicate if you acknowledge and accept this requirement.

Yes, I acknowledge and accept that the position may require working rotating shifts, including nights, weekends, and holidays.
No, I'm unable to work rotating shifts which includes nights, weekends, and holidays.
 

Do you acknowledge and accept the following:

In order to practice at San Joaquin General Hospital, you must be credentialed and  granted privileges through the San Joaquin General Hospital Committee on Interdisciplinary Practice (CIDP) within ninety (90) days of appointment and in accordance with medical staff bylaws and state regulations.  New employees may be granted temporary privileges by the Medical Director or designee, pending Committee Interdisciplinary Practice approval.  Eligibles may be certified only to job vacancies in the area of specialization in which they posses specialized education and certification. Additionally, the successful completion of approved nursing training programs, possession of specific nursing experience or the possession of specified professional certificates may be required depending on the nature of the area of assignment.

Yes No