San Joaquin County Human Resources Division
#1118-RH1104-01
Supplemental Questionnaire
| Last Name | |
|---|---|
| First Name |
|
Please attach applicable licenses and certificates to the online employment application. Failing to provide a copy of your licenses and certificates may result in a failure to move forward in the selection and hiring process. All relevant RN experience should be included in the application. |
|
1. Education: Do you possess a Bachelor's Degree or Master's Degree in Nursing or closely-related field. (If a closely-related field, please be sure to clearly indicate the type of degree in the "education" portion of your employment application.) |
| Bachelor's Degree in Nursing |
| Master's Degree in Nursing |
| Bachelor's or Master's in closely-related field |
| Does not apply |
|
2. License: Provide your current RN License Number so that it can be source verified with the State of California Board of Registered Nursing. If you do not possess a valid or current RN License, please note "N/A": |
|
|
|
3. 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 to your online application where resume attachment is offered, e-mailed to jripp@sjgh.org, or faxed Attn: Joanne to (209) 468-6271. Please indicate if you possess any of the following certificates (check all that apply): |
| ACLS |
| BLS |
| CPR |
| PALS |
| Preceptor course or Nursing Trainer certificate |
| Advanced Fetal Heart Monitoring course certificate |
| Chemotherapy certification |
| Critical Care course certificate |
| ED Essentials Course certificate or equivalent |
| Fetal Heart Monitoring course certificate |
| Fluid and Electrolyte course certificate |
| Hemodynamic Monitoring certificate |
| ICN course certificate |
| MSE Triage course certificate |
| MICN-Code 3 Clearance |
| Neonatal Resuscitation Program (NRP) |
| PICC (Peripherally Inserted Central IV Catheters) certificate |
| Renal Failure course |
| National certifications (CEN, CCRN, CNN, CDN, CPAN, CNOR, PCCN) |
| Trauma Nursing Core Course (TNCC) |
| Other |
| None of the above |
|
If other was selected, identify the licenses and/or certificates. |
|
|
|
4. San Joaquin General Hospital is a 24/7 running facility. Employees are expected to be open to working rotating shifts that will include nights, weekends and holidays.
As a condition of employment, Staff Nurses assigned to the Perioperative Units (Surgery-Recovery, PACU) must be able to take standby call on a rotational basis. While on call, nurses must possess the ability to return to the hospital within 30 minutes. Are you available to work in a position that has these requirements?
|
|
Yes, I understand that this position requires the ability to work rotating hours and take standby call. Should I be selected for the position, I have the ability to meet the 30 minute response requirement while on Standby Call duty. |
|
No, I understand that this position requires the ability to work rotating hours and take standby call, however I am unable to meet the 30 minute response requirement for this unit. |
|
5. Note: Candidates hired in the following units must successfully pass a California Department of Corrections and Rehabilitation (CDCR) background investigation and must maintain their clearance for continued employment: Medical-Surgical, Medical Guarded Unit, Float Pool. Please indicate that you have read and understand this condition of employment for the units identified. |
|
I understand and agree with this condition of employment. |
|
I am not interested in being referred to the listed departments. |