Official SealSan Joaquin County Human Resources Division


#1119-RH1170-TM
Supplemental Questionnaire

Last Name
First Name
1.

Education:

Have you completed an approved nurse midwife educational program that is recognized by the American College of Nurse Midwives?

Yes No
 

If yes, please identify the following:

  • Date educational program was successfully completed
  • Name of institution attended
2.

Licenses & Certificates:

Are you currently licensed as a Registered Nurse in the State of California?

Yes No
 
If yes, please provide your license number below:
 
Do you possess a valid California Nurse Midwife Certificate?
Yes No
 
If yes, please provide the certificate number:
3.

Do you acknowledge that you must possess a valid California Nurse Midwife furnishing number within one year of appointment to the class of Nurse Midwife?

Yes No
4.

Experience:

Please use the space below to provide a detailed description of any existing Nurse Midwife experience that you possess. Include in your answer:

  • Dates of Employment
  • Job Title
  • Employer
  • Duties Performed
  • Note whether the experience was in a delivery or clinical non-delivery environment and/or whether you possess experience in both these areas
5.

Please use the space below to provide a detailed description of registered nursing experience that you possess in a Labor and Delivery Recovery and Post-Op environment. Include in your answer:

  • Dates of Employment
  • Job Title
  • Employer
  • Duties Performed