Official SealSan Joaquin County Human Resources Division


#0319-RH1103-TM
Supplemental Questionnaire

Last Name
First Name

 

Please note that when selecting the inpatient units of interest, vacancies in the units may not be currently available although effort is made to hire candidates into their primary department of interest. Shifts may include working nights, weekends, and holidays.


1

Please provide your RN license number.

2

Do you possess at least six months of full-time (40 hours per week) paid registered nursing 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
Yes No
2a

If yes, in the box below, provide the following information for each employer where you were employed as a registered nurse in an acute care hospital. Information should also be included in the Employment section of the application.

Employer #1

  • Name of the facility
  • Dates of employment
  • Hours worked per week
  • Nursing unit assigned
2b

Employer #2

  • Name of the facility
  • Dates of employment
  • Hours worked per week
  • Nursing unit assigned
3

Please select from the following list of inpatient units for which you are interested in being referred for hiring consideration:

Cardiac Cath Lab / EKG
Emergency Department
Float Pool Unit*
GI / Short Stay Surgery
Hemodialysis
Intensive Care Nursery
Intensive Care Unit
Labor-Delivery-Recovery-Post Partum
Medical-Surgical Unit*
Medical Guarded Unit (MGU)*
Pediatrics
Post-Anesthesia Care Unit (PACU)
Progressive Care Unit (PCU)
Surgery Recovery**
All of the above
Other
3a

If "other" was selected, please identify the department(s) below.

4

*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: Float Pool, 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.
5

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

I acknowledge the term and condition of employment listed above.
I am not interested in being referred to the Surgery-Recovery unit.
6

CERTIFICATIONS:

Please select from the list below for which you currently possess active certifications (check all that apply):

ACLS
BLS
CCRN (or other National Certification)
Chemotherapy
CPR
EKG or course completion
PALS
None of the above
Other
7

As a 24-7 facility, San Joaquin General Hospital employees may be asked to be available to work any shift.

Listed below are various examples of shifts. Check all shifts for which you are available to work.

Days: 7:00AM - 3:00PM
PMs: 3:00PM - 11:30PM
Nights: 10:30PM - 7:00AM