Official SealSan Joaquin County Human Resources Division

Supplemental Questionnaire

Last Name
First Name

This is a department promotional opportunity. In order to qualify, you must be currently employed by San Joaquin General Hospital and meet promotional requirements under Civil Service Rule 10, Section 3. Are you currently employed with San Joaquin General Hospital?

Yes No

Please review the following and check all that apply. (Please note that proof of successful completion of training courses or National Certification will need to be submitted with your employment application in order to be considered. You may e-mail attachments to or attach in your online application on the tab that offers resume'' attachment):

I currently possess a Bachelor's Degree in Nursing or related field (Please clearly list degree on education portion of your application).
I have successfully completed a Nurse Practitioner Program.
I possess National Certification. (Must submit proof so that it can be source verified).
I have successfully completed specialty training courses. (Please note that proof of completion must be submitted with employment application in order to be considered).
I have not completed any of the programs listed above.


The following Licenses/Certifications are all required to qualify for this position: RN License, Nurse Practitioner Certification and current Furnishing License all with the CA Board of Registered Nursing. Please provide the license/certification number for each so that it can be source verified by Human Resources. If you do not possess the license/certification, please note "N/A" in the text box:


California Registered Nurse License:


Nurse Practitioner Certification Number:


Furnishing License Number:


This position will be assigned to the Ambulatory Care Services division and will require at least four (4) years paid Nurse Practitioner experience in which at least one (1) year of the experience is from an Ambulatory Care Services Clinic or similar environment.  Please provide the name of your employer, dates of employment and a description of duties performed as a licensed Nurse Practitioner below. 


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