Official SealSan Joaquin County Human Resources Division

Supplemental Questionnaire

Last Name
First Name


Please attach applicable licenses and certificates to the online employment application where resume attachment is offered.  Failing to provide a copy of your licenses and certificates may result in a failure to move forward in the selection and hiring process.  A copy of the source verification from the California Board of Registered Nursing (BRN) is not accepted in lieu of a valid and current RN license.  All relevant RN experience should be included in the application.

Based upon the certifications and licenses identified in the supplemental questionnaire, a determination will be made as to which of the inpatient units you may be qualified.  Each unit requires specific experience, licenses, and certificates as identified in the San Joaquin County CNA MOU



Do you possess a Bachelor's Degree or Master's Degree in Nursing or closely-related field. (If a closely-related field, please be sure to clearly indicate the type of degree in the "education" portion of your employment application.)

Bachelor's Degree in Nursing
Master's Degree in Nursing
Bachelor's or Master's in closely-related field


Provide your current RN License Number so that it can be source verified with the State of California Board of Registered Nursing. If you do not possess a valid or current RN License, please note "N/A":


The following section will be utilized to determine if you possess the license and/or certifications required to qualify as a Staff Nurse IV for a specific inpatient unit.  Copies may be attached to your online application where resume attachment is offered, emailed to, or faxed to (209) 468-6271 ATTN: K Parker.

Please indicate if you possess any of the following certificates:

Preceptor course or Nursing training certificate
Advanced Fetal Heart Monitoring course certificate
Chemotheraphy certification
Critical Care course certificate
ED Essentials Course certificate or equivalent
Fetal Heart Monitoring course certificate
Fluid and Electrolyte course certificate
Hemodynamic Monitoring certificate
ICN course certificate
MSE Triage course certificate
MICN-Code 3 clearance
Neonatal Resuscitation Program (NRP)
PICC (Peripherally Inserted Central IV Cathers) certificate
Renal Failure course
National certifications (CEN, CCRN, CNN, CDN, CPAN, CNOR, PCCN)
Trauma Nursing Core Course (TNCC)
None of the above

If other was selected, identify the licenses and/or certificates.


San Joaquin General Hospital is a 24/7 running facility. Employees are expected to be open to working rotating shifts that will include nights, weekends and holidays.


As a condition of employment, Staff Nurses assigned to the Perioperative Units (Surgery-Recovery, PACU) must be able to take standby call on a rotational basis. While on call, nurses must possess the ability to return to the hospital within 30 minutes. Are you available to work in a position that has these requirements?


Yes, I understand that this position requires the ability to work rotating hours and take standby call. Should I be selected for the position, I have the ability to meet the 30 minute response requirement while on Standby Call duty.
No, I understand that this position requires the ability to work rotating hours and take standby call, however I am unable to meet the 30 minute response requirement for this unit.

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: Medical-Surgical, Medical Guarded Unit, Float Pool.

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.