Official SealSan Joaquin County Human Resources Division


#0919-RH1104-02
Supplemental Questionnaire

Last Name
First Name
1.

PATTERN I 

Experience - Do you possess two years of progressively responsible experience as a registered nurse, one year of which includes Clinical Information Systems experience, in an acute care or ambulatory care setting at a level equivalent to a San Joaquin County Staff Nurse III?

Yes No
 

If you answered yes, provide the following:

  • Employment timeline, including the dates in which you gained Clinical Information Systems experience
  • Name of the healthcare facility
  • Job title
  • Detailed description of Clinical Information System duties/responsibilities
2.

OR PATTERN II

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

Yes No
 

If you answered yes, provide the following:

  • Type of degree
  • Name of educational facility in which degreee was obtained
  • Date of graduation
2b.

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

Yes No
 

If you answered yes, provide the following:

  • Timeline of employment gaining Clinical Information Systems experience
  • Name of healthcare facility
  • Job title
  • Detailed description of Clinical Information Systems duties/responsibilities
3.

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.

4.

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

Advanced Cardiac Life Support (ACLS) Certification
SJC Mobile Intensive Care Nurse (MICN) Certification
Preceptor Class or Equivalent
Critical Care Class
PALS Certification
EKG Class
ED Essentials or Equivalent
MSE Triage
I do not possess any of the above certification or class completions