Official SealSan Joaquin County Human Resources Division


#0820-RH3001-TM
Supplemental Questionnaire

Last Name
First Name
1

San Joaquin General Hospital is a 24/7 operating facility. Incumbents employed with San Joaquin General Hospital must have the ability to work rotating shifts which include nights, weekends and holidays. Please indicate if you acknowledge and accept this requirement.

Yes, I acknowledge and accept that the position may require working rotating shifts, including nights, weekends, and holidays.
No, I'm unable to work rotating shifts which includes nights, weekends, and holidays.
2

PATTERN I

Do you possess six months of full time equivalent hours (1,040 paid hours) of experience as a Nursing Assistant Trainee with San Joaquin General Hospital?

Yes No
 

If yes, please provide dates of employment as a Nursing Assistant Trainee with San Joaquin General Hospital and the number of hours worked per week.

3

PATTERN II/III

Please indicate if you possess the following full-time equivalent (40 hours per week) paid experience:

six months (1040 hours) of performing non-professional nursing work in an acute care hospital
one year (2080 hours) performing non-professional nursing work in a convalescent hospital, home health care agency, or similar sub-acute facility.
none of the above
 

If you possess the required experience, provide the following information:

  1. Employer / Facility / Agency
  2. Dates of employment (from/to)
  3. Number of hours worked per week
  4. Job Title
  5. Specific duties performed
4

SUBSTITUTION PATTERN

Please indicate if you have successfully completed an appropriate clinical training in one of the following:

Licensed Vocational Nurse curriculum
Registered Nurse curriculum
None of the above
 

If yes, please list the name of the institution and date of completion.

5

Nursing Assistants assigned to the Hospital’s Labor & Delivery Department may be utilized at OB Techs. This role requires the employee to work as a scrub in a surgical environment for patients in the Labor & Delivery Department. Do you possess experience as an OB Tech or similar position in an acute or sub-acute care facility?

Yes No
 

If yes, please provide the following information:

  1. Job title
  2. Employer
  3. Starting and ending dates of employment
  4. Number of hours worked per week
  5. Specific OB scrub duties performed
6

Please indicate below your interest in being referred to the Labor & Delivery Department for Nursing Assistant positions that may be utilized as OB Scrub Techs. Please note, Nursing Assistants working in this capacity are in a surgical environment that range from scheduled to emergency procedures and must have the ability to stand for long periods of time:

Yes, I would like to be referred to Nursing Assistant positions that may be utilized as OB Scrub Techs.
No, I would not like to be referred to Nursing Assistant positions that may be utilized as OB Scrub Techs.