Official SealSan Joaquin County Human Resources Division


#0120-RH1105-AC
Supplemental Questionnaire

Last Name
First Name
1.

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. Are you available to work in a position that has these requirements?

Yes No
2.

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.

3.

Do you possess two (2) years of paid registered nurse experience in an acute care Medical/Surgical Department?

Yes No
 

If yes, please indicate your job title, employer, dates of employment and hours per week worked. Include in your answer a detailed description of the advanced administrative and/or clinical nursing duties you performed.

4.

Do you possess a Bachelor's Degree in Nursing? (Please Note: If yes, be sure to clearly identify your degree either on the education portion of your employment application or resume as it will be source verified).

Yes No
5.

Certifications:

Please mark active certifications that you currently possess: (Check all that apply)

BLS Certification
ACLS Certification
PALS Certification
Chemotherapy Certification
EKG Certification or Course Completion
CCRN - Critical Care Nurse National Certification
Preceptor or Adult Trainer Course Completion
I currently do not possess any of the certifications noted above