Official SealSan Joaquin County Human Resources Division


#1220-RH1105-TM
Supplemental Questionnaire

Last Name
First Name
1.

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:

2.

The following courses/certifications are all required for the position of Staff Nurse V-Clinical Inpatient for the Emergency Department. (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 an ED Essentials Course or equivalent. (attach certificate of completion to application)
Yes, I have completed an MSE Triage Course. (attach certificate of completion to application)
Yes, I have completed a Preceptor Course or equivalent. (attach certificate of completion to application)
Yes, I have completed a PALS Course. (attach certificate of completion to application)
Yes, I possess MICN-Code 3 Clearance. (attach certificate of completion to application)
Yes, I possess current ACLS Certification. (attach certificate of completion to application)
No, I do not possess any of the certifications noted above.
3.

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.
4.

Do you possess at least 3 years of paid journey-level RN experience in a large acute care hospital's Emergency Department including one year equivalent to a SN IV at San Joaquin County?

Yes No
 

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

5.

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. 

6.

Please describe your experience in working with nursing or healthcare administration on developing the clinical skills of nursing staff in an ED environment.

7.

Please describe your experience and understanding of the emergency nurse's role when working in a trauma facility. Include in your answer if you have ever educated new nurses in this type of environment.