Official SealSan Joaquin County Human Resources Division


#0121-RH1106-AC
Supplemental Questionnaire

Last Name
First Name
1

Please provide your RN license number:
2

EDUCATION

Please indicate if you possess the following degree(s) from an accredited college/university.

This information should be clearly identified in the Education section of the employment application.
Associates degree - Nursing (ADN)
Bachelors degree - Nursing (BSN)
Masters degree - Nursing (MSN)
Other (clearly identify the degree and discipline in the Education portion of the application)
None of the above

 

The following section will be utilized to determine if you possess the required licenses and/or certifications to qualify as a Staff Nurse V for the specific inpatient unit. Please check all that apply. Copies may be attached to your online application, emailed to jripp@sjgov.org, or faxed to (209) 468-0508, Attn: SJGH Recruitment.
3

Please indicate if you possess any of the following certificates (select all that apply):
ACLS
BLS
PALS
Preceptor course or Nursing Trainer certificate
Chemotherapy certificate
EKG class
PICC
National Certification
Other
None of the above
 

If "Other" was selected, identify the licenses and/or certificates that you possess.
4

Please identify the number of years that you possess of full-time (40 hours per week) paid RN experience in an acute care hospital.
less than 6 months
more than 6 months but less than 1 year
more than 1 year but less than 3 years
more than 3 years
I do not possess any RN experience in an acute care hospital
5

Please provide a brief description of your RN experience in an acute care hospital Medical Surgical Unit.  Include the following:

  1. Acute Care Hospital
  2. Dates of employment (from/to)
  3. Number of hours worked per week
  4. Specific duties and responsibilities
6

Note: Candidates hired in some units must successfully pass a California Department of Corrections and Rehabilitation (CDCR) background investigation and must maintain their clearance for continued employment.

Please indicate if you have read and understand this condition of employment.
Yes No