Official SealSan Joaquin County Human Resources Division


#0121-RH1106-A1
Supplemental Questionnaire

Last Name
First Name
1.

License:

Provide your current RN License Number so that it can be source verified with the State of California Board of Registered Nursing. If you do not possess a valid or current RN License, please note "N/A":
2.

Education:

Do you possess a Bachelor's Degree in Nursing or closely related field. (If, yes, please be sure to clearly indicate the status of your degree in the "education" portion of your employment application.)
Yes No
3.

Do you possess National Certification? (If, yes, please be sure to clearly indicate the status of your degree in the "education" portion of your employment application.)
Yes No
4.

The following certifications are requirements for the Intensive Care Nursery (ICN). Have you successfully completed the following nursing classes/certification courses? (Check All that Apply; Proof of completion must be submitted with employment application.)
Neonatal Resuscitation Program (NRP)
ICN Class
Preceptor Class or equivalent
Transport Nurse Class
I have not completed any certifications/classes noted
5.

I possess the following number of years of licensed Registered Nurse experience in an acute care hospital Intensive Care Nursery or Neonatal Intensive Care Unit. (Employer, Dates of Employment, Hours Per Week Worked, and nursing duties must clearly be defined on the "experience" portion of your employment application and/or resume):
1 year of paid RN experience
2-4 years of paid RN experience
5 or more years of paid RN experience
I possess less than 1 year of paid RN experience
I do not possess any paid RN experience in this type of Inpatient Unit