Official SealSan Joaquin County Human Resources Division


#1218-RH0175-01
Supplemental Questionnaire

Last Name
First Name
1.
Do you possess a Bachelor's Degree in Nursing?
Yes No
 

If yes, what is the name of the institution from which the degree was received?
2.
Do you possess a minimum of three years experience as a clinical nursing instructor in an acute care facility?
Yes No
 

If yes, please identify (in detail) the following:

  •   Time frame (month/year start and end) for experience
  •   Average number of hours worked per week
  •   Responsibilities/duties you performed
  •   Approximate size of nursing staff (at all facilities where you served as a nursing educator) 

 
3.
Are you substituting possession of a Master's Degree in Nursing or related field for one year of the required experience?
Yes No
 

If you answered yes to the above question, please provide the name of the institution from which the degree was obtained. 
4.

Do you possess current registration as a nurse in the State of California?
Yes No
 

If yes, please provide your registration number and expiration date.
5.

Please outline in detail a nursing education approach and/or training plan that you developed/implemented as part of your current/prior experience.  As a minimum, you should include:

  • Approach used to identify training requirements.
  • Source data collection strategy to plan approach.
  • Interactions with technical/medical resources to implement education approach/plan.
  • Analysis used to formulate presentation approach.
  • Presentation media used.
  • Number of staff trained.
  • Positive/negative feedback.
  • Lessons learned i.e. "what could have been done better."