Official SealSan Joaquin County Human Resources Division


#0519-RH1104-T2
Supplemental Questionnaire

Last Name
First Name
1

Please provide your California RN license number.
2

Education:

Do you possess a Bachelor's Degree in Nursing or closely related field. (If yes, please be sure to clearly indicate the status of your degree in the "education" portion of your employment application.)
Yes No
3

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
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.
3a

Please describe your journey level nursing experience in an acute care hospital. Include the following information:

  1. Employer
  2. Job Title
  3. Dates of employment (from/to)
  4. Number of hours worked per week
  5. Brief summary of the specific nursing duties performed
4

Do you possess current state, national, or other certifications in case management? (If yes, submit certification copies to kparker@sjgh.org or fax to (209) 468-6271).
Yes No
5

Do you possess experience with case management/utilization management software systems?
Yes No
5a

If yes, please identify the software systems for which you possess experience utilizing. (If none, indicate "N/A")