Official SealSan Joaquin County Human Resources Division


#0720-RH1167-TM
Supplemental Questionnaire

Last Name
First Name

1.

The following Licenses/Certifications are all required to qualify for this position: RN License, Nurse Practitioner Certification and current Furnishing License all with the CA Board of Registered Nursing. Please provide the license/certification number for each so that it can be source verified by Human Resources. If you do not possess the license/certification, please note "N/A" in the text box:


 

California Registered Nurse License:

 

Nurse Practitioner Certification Number:

 

Furnishing License Number:

2.

This position will be assigned to the Ambulatory Care Services division and will require at least four (4) years paid Nurse Practitioner experience in which at least one (1) year of the experience is from an ambulatory care clinic or similar environment.  Please provide the name of your employer, dates of employment and a description of duties performed as a licensed Nurse Practitioner below. 

3.

Do you acknowledge and accept the following:

In order to practice at San Joaquin General Hospital, you must be credentialed and  granted privileges through the San Joaquin General Hospital Committee on Interdisciplinary Practice (CIDP) within ninety (90) days of appointment and in accordance with medical staff bylaws and state regulations.  New employees may be granted temporary privileges by the Medical Director or designee, pending Committee Interdisciplinary Practice approval. Eligibles may be certified only to job vacancies in the area of specialization in which they posses specialized education and certification.  Additionally, the successful completion of approved nursing training programs, possession of specific nursing experience or the possession of specified professional certificates may be required depending on the nature of the area of assignment.

Yes No