Official SealSan Joaquin County Human Resources Division


#0419-RH1104-01
Supplemental Questionnaire

Last Name
First Name
1.

Experience - Do you possess two years of progressively responsible experience as a registered nurse in an acute care setting at a level equivalent to a San Joaquin County Staff Nurse III?

Yes No
2.

If you answered Yes, please describe and include the following:

  • Name of employer
  • Dates of employment
  • Job Title
  • Number of hours worked per week
  • Specific job duties performed

Note:  A resume is not accepted in lieu of completing this question.  Providing all information requested relative to your experience will assist in assessing your qualifications.

3.

OR       PATTERN II

Education: Do you possess a Bachelor's Degree in Nursing, Health Science, or closely related field?

Yes No
4.

If you answered yes, provide the following:

  • Type of degree
  • Name of educational facility in which degreee was obtained
  • Date of graduation
5.

Experience:  Do you possess one year of progressively responsible experience as a registered nurse in an acute care hospital at a level equivalent to a San Joaquin County Staff Nurse III?

Yes No
6.

If you answered Yes, please describe and include the following:

  • Name of employer
  • Dates of employment
  • Job Title
  • Number of hours worked per week
  • Specific job duties performed

Note:  A resume is not accepted in lieu of completing this question.  Providing all information requested relative to your experience will assist in assessing your qualifications.

7.

License and Certificates:  Do you possess current and valid registration as a registered nurse in the State of California? if yes, provide the license number and the expiration date.

8.

Special Requirements:  Mark active certifications/classes that you currently possess or have completed. (Check all that apply)

ACLS
BLS
Preceptor course or Nursing Trainer certificate
National certifications (CEN, CCRN, CNN, CDN, CPAN, CNOR, PCCN)
Other
None of the above