Official SealSan Joaquin County Human Resources Division


#0119-RH1103-TM
Supplemental Questionnaire

Last Name
First Name

 

You are applying for a position in Correctional Health Services, which provides health care to adult inmates at the San Joaquin County jail facility.

Prior to working in the jail facility, the selected candidate may receive a conditional, temporary clearance to begin employment. To retain employment, the candidate must subsequently successfully pass the security clearance, and, once employed, the employee must maintain the security clearance.

The security clearance is initiated through a background investigation conducted by the Sheriff’s Office. The background investigation requires the completion of an extensive questionnaire called “Personal History Questionnaire” and is used by the Sheriff’s Office to conduct the background investigation. 

The security clearance is a mandatory condition of employment, and the loss of the security clearance will result in termination from County employment in accordance with the rules and regulations governing County employment.


1

Have you read the above information and understand that passing and maintaining a security clearance is a condition of employment?

Yes No
2

Are you willing to submit to a background investigation conducted by the Sheriff’s Office?

Yes No
3

Have you previously had a security clearance in a detention facility or law enforcement agency?

Yes No
 

If you answered yes, provide the name of employer and dates of employment.

4

Have you failed a security clearance in the past for a detention facility or law enforcement agency?

Yes No
 

If you answered yes, provide the name of employer and date you failed the security clearance.

5

Have you ever had a security clearance revoked while employed in a detention facility or law enforcement agency?

Yes No
 

If you answered yes, provide the name of the employer and the reason your security clearance was revoked.

6

Are you willing to work with adult inmates who are incarcerated?

Yes No
7

Employment history is part of the background investigation process. Have you ever been terminated from a job or resigned from a job to avoid termination (not including involuntary layoff)?

Yes No
 

If you answered yes, provide the name of employer and date of separation

8

I understand that a thorough background investigation will be conducted as part of the selection process. I hereby certify that I have personally completed each question and that all statements are true and complete. I understand that any omissions or misstatements of facts may be considered deliberate falsification on my part, which will subject me to disqualification or, if discovered after my employment, to termination in accordance with County rules and regulations.

Yes No
9

I understand that if I successfully pass the background investigation and obtain the security clearance, I will be expected to maintain my security clearance as a condition of my employment and failure to do so will result in the termination of my employment with the County in accordance with County rules and regulations.

Yes No
10

If Per Diem positions become available, would you be interested in being referred? 

Defintion of Per Diem: Non-Benefited Staff Nurse positions. Employees in this status shall receive supplemental pay (20%) in lieu of benefits. Per Diem nurses work as needed.

Yes No
11

Are you currently registered as a nurse or possess an interim permit issued by the State of California Board of Nursing (BRN)?

 

Yes No
12

Please provide your RN or interim permit license number.

13

Do you possess a current CPR certificate? (submit a copy of your CPR certificate to Human Resources)

Yes No
 

In order to ensure your nursing experience meets the qualifications required as a Staff Nurse III – Inpatient in San Joaquin County Correctional Health Services, please read the following paragraphs on what is considered “acute care (hospital) setting ” before answering the questions on whether you have the required one year of experience as a registered nurse in an acute care setting at a level equivalent to San Joaquin county Staff Nurse III-Inpatient.  

Acute care is a level of care where patients are treated for a brief acute episode of illness, for conditions that are the results of a disease or trauma, and during recovery from surgery. Acute care is generally only provided in hospitals where all of the following medical units/services are provided:

  • Emergency
  • Medical Surgical
  • Labor and Delivery
  • Intensive Care Unit

Nurses who work in a health care facility that primarily provides care for chronic health conditions or sub-acute care, or is a skills nursing facility (SNf) do not meet the definition of “acute care setting” for the purpose of meeting the minimum qualifications of Staff Nurse III - Inpatient in Correctional Health Services.

14. Do you have at least six months of experience as a registered nurse in an acute care (hospital) setting?

Yes No
 

If yes, please provide the following information for each employer where you were employed as a registered nurse in an acute care (hospital) setting.

Employer #1

Name of the hospital:  ___________________________________

Dates of employment:  ___________________________________

Hours of work per week: ____________________________________

 

Does this hospital have the following medical units/services?

A. ER

 

Yes No
 

If yes, did you work in this unit?

Yes No
 

B. Medical Surgical

Yes No
 

If yes, did you work in this unit?

Yes No
 

How many patient beds are in the Medical Surgical unit?

 

C. Labor and Delivery (Maternity)

Yes No
 

If yes, did you work in this unit?

Yes No
 

D. Intensive Care Unit

Yes No
 

If yes, did you work in this unit?

Yes No
 

Employer #2

Name of the hospital:  ___________________________________

Dates of employment:  ___________________________________

Hours of work per week: ____________________________________

 

Does this hospital have the following medical units/services?

A. ER

 

Yes No
 

If yes, did you work in this unit?

Yes No
 

B. Medical Surgical

Yes No
 

If yes, did you work in this unit?

Yes No
 

How many patient beds are in the Medical Surgical unit?

 

C. Labor and Delivery (Maternity)

Yes No
 

If yes, did you work in this unit?

Yes No
 

D. Intensive Care Unit

Yes No
 

If yes, did you work in this unit?

Yes No
15.

You acknowledge that you are available to work every other weekend and on an as needed basis. 

Yes No