Official SealSan Joaquin County Human Resources Division

Supplemental Questionnaire

Last Name
First Name

Licenses & Certificates:

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

Yes No

If yes, please list your license number and expiration date:


The following courses/certifications are all required for the position of Staff Nurse V-Clinical Inpatient for the Intensive Care Nursery. (NOTE: Copies of certifications and course completions must be attached to your employment application in order to be considered). Please check all that apply:

Yes, I have completed a Neonatal Resuscitation Program.
Yes, I have completed an ICN class.
Yes, I have completed a Preceptor class or equivalent.
Yes, I have completed the Transport Nurse class.
No, I do not possess any of the certifications noted above.

Please note the education and national certification that you possess below. Education must clearly be annotated on your employment application. A copy of your National Certification must be submitted with your employment application in order to be considered. Please check all that apply:

Yes, I possess a Bachelor's of Science Degree in Nursing or related field.
Yes, I possess National Certification.
I do not possess a Bachelor's Degree in Nursing or National Certification.

Do you possess at least two years of paid journey-level RN experience in an acute care hospital's Intensive Care Nursery including one year equivalent to a Staff Nurse IV in San Joaquin County?

Yes No

If yes, please provide a detailed description of the journey-level nursing duties you performed in an Intensive Care Nursery. Include in your answer: name of employer, dates of employment, and hours per week worked.


Please describe your experience as a clinical educator. Include in your answer the staff you educated, your precepting approaches, and how you monitored the success of the staff you guided. 


Please describe your experience in working with nursing or healthcare administration on developing the clinical skills of nursing staff in an Intensive Care Nursery setting.