Official SealSan Joaquin County Human Resources Division


#1019-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 failure to move forward in the selection and hiring process. Copies of licenses and certifications may be submitted in the online application, emailed to kparker@sjgov.org, or faxed to (209) 468-0508.  All relevant RN experience should be included in the application.


1.

Licenses & Certificates:

Are you currently licensed as a registered nurse in the State of California?

Yes No
 

If yes, please list the license number and expiration date.

2.

Education:

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

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

Associates degree - Nursing (ADN)
Bachelor's degree - Nursing (BSN)
Master's degree - Nursing (MSN)
Other (Clearly identify the degree and discipline in the Education portion of your application)
None of the above
3.

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

ACLS
BLS
Hemodynamic Monitoring Class
Preceptor course or Nursing Trainer certificate
National Certification (CNOR)
Other
None of the above
4.

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

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 Operating Room experience.  Include the following in your response:

  • Acute Care Hospital
  • Dates of Employment
  • Number of Hours worked per week
  • Specific duties and responsibilities