Official SealSan Joaquin County Human Resources Division


#0119-RH1106-01
Supplemental Questionnaire

Last Name
First Name

 

Copies of all licenses and certifications must be submitted with the completed employment application. Failing to provide the required documents may result in a failure to move forward in the selection and hiring process. Copies of the licenses and certifications may be submitted in the online application ("Other" tab), emailed to jripp@sjgh.org, or faxed to (209) 468-6271. All relevant RN experience should be included in the application.

To qualify as a Staff Nurse V-Assistant Nursing Department Manager or Clinical requires specific experience, licenses, and certificates for the designated nursing unit as identified in the San Joaquin County CNA MOU - Career Ladder. Availability of open positions in the various nursing units may change as they are filled.

All offers of employment are conditional upon successfully passing a pre-employment drug screen and an arduous physical.


1

Please provide your RN license number:

2

EDUCATION

Please indicate if you possess the following degree(s) from an accredited college/university.

This information should be clearly identified in the Education section of the employment application.

Associates degree - Nursing (ADN)
Bachelors degree - Nursing (BSN)
Masters degree - Nursing (MSN)
Other (clearly identify the degree and discipline in the Education portion of the application)
None of the above

 

The following section will be utilized to determine if you possess the required licenses and/or certifications required to qualify as a Staff Nurse V for the specific inpatient unit(s) selected. Please check all that apply. Copies may be attached to your online application when prompted for a resume, emailed to jripp@sjgh.org, or faxed to (209) 468-6271, Attn: Joanne.


3

Please indicate if you possess any of the following certificates (select all that apply):

ACLS
BLS
CPR
PALS
Preceptor course or Nursing Trainer certificate
Advanced Fetal Heart Monitoring course certificate
Chemotherapy certification (may be required based upon assignment in Medical Surgical Department)
EKG class
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
Invasive/Cardiac Catherterization Registered Cardiovascular Invasive Specialist (RCIS)
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)
TNCC or ENPC
Other
None of the above
3a

If "Other" was selected, identify the licenses and/or certificates that you possess.

4

Please identify the number of years of full-time (40 hours per week) paid RN experience in an acute care hospital.

Please note: 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
less than 6 months
more than 6 months but less than 1 year
more than 1 year but less than 3 years
more than 3 years
I do not possess any RN experience in an acute care hospital.
5

Please provide a brief description of your RN experience in an acute care hospital Emergency Department. Include the following:

  1. Acute Care Hospital
  2. Dates of employment (from/to)
  3. Number of hours worked per week
  4. Specific nursing duties and responsibilities
  5. Charge nurse experience
  6. Experience precepting staff

If your experience includes working as a traveler/registry, clearly identify each acute care hospital for which you were assigned.

6

The following are the listing of San Joaquin General Hospital's Inpatient departments. Names are referred to departments based upon the preferences selected by the candidates and for which they possess the required certifications and experience. Not all of the listed departments currently have vacancies to be filled. As vacancies occur, referrals will be sent to the departments for hiring consideration.

Please select the department(s) to which you would be interested in referral. (Check all that apply)

*Please note that as a condition of employment, candidates selected for these units must successfully pass a California Department of Corrections and Rehabilitation (CDCR) background investigation conducted by the CDCR. Candidates must also maintain their CDCR clearance for continued employment in these units.

Cardiac Cath Lab (CCL)
Emergency Department
Family Maternity Center (Labor and Delivery)
Post Partum, Pediatrics
Hemodialysis Unit
Intensive Care Nursery (ICN)
Intensive Care Unit
Medical Guarded Unit (MGU)*
Medical/Surgical Unit*
OR** (Surgery/Recovery - Must be able to report to work within 30 minutes of call.)
Post-Anesthesia Care Unit (PACU)
Progressive Care Unit (PCU)
7

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, and OR.

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.
8

**Note: If Surgery-Recovery has been selected as a unit of interest, positions in this unit must be able to report to work within 30 minutes of call back.

Yes, I acknowledge the term and condition of employment listed above.
I am not interested in being referred to the Surgery-Recovery unit.