Official SealSan Joaquin County Human Resources Division


#0620-RH1104-SR
Supplemental Questionnaire

Last Name
First Name
1.

PATTERN I 

Experience - Do you possess two years of progressively responsible experience as a registered nurse, one year of which includes Clinical Information Systems experience, in an acute care or ambulatory care setting at a level equivalent to a San Joaquin County Staff Nurse III?
Yes No
 

If you answered yes, provide the following:

  • Employment timeline, including the dates in which you gained Clinical Information Systems experience
  • Name of the healthcare facility
  • Job title
  • Detailed description of Clinical Information System duties/responsibilities
2.

OR       PATTERN II

Education: Do you possess a Bachelor's Degree in Nursing, Health Science, or closely related field?
Yes No
 

If you answered yes, provide the following:

  • Type of degree
  • Name of educational facility in which degreee was obtained
  • Date of graduation
2b.

Experience:  Do you possess one year of progressively responsible Clinical Information Systems experience as a registered nurse in an acute care hospital or ambulatory care setting at a level equivalent to a San Joaquin County Staff Nurse III?
Yes No
 

If you answered yes, provide the following:

  • Timeline of employment gaining Clinical Information Systems experience
  • Name of healthcare facility
  • Job title
  • Detailed description of Clinical Information Systems duties/responsibilities
 

Please indicate if you possess any of the following certificates (check all that apply). Note: Copies of certificates may be attached in your online application, emailed to jripp@sjgov.org, or faxed to  (209) 468-0508, ATTN: Joanne Ripp.
Preceptor course or Nursing Trainer certificate
ACLS Certification
BLS Certification
National certifications (CEN, CCRN, CNN, CDN, CPAN, CNOR, PCCN)
Other
3.

License and Certificates:  Do you possess current and valid registration as a registered nurse in the State of California? if yes, provide the license number and the expiration date.
 

If you selected "other", please describe: