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#0221-RH1104-TM
Supplemental Questionnaire

Last Name
First Name
1.

Education:

Do you possess a Bachelor's Degree or Master's Degree in Nursing or closely-related field. (If a closely-related field, please be sure to clearly indicate the type of degree in the "education" portion of your employment application.)

Bachelor's Degree in Nursing
Master's Degree in Nursing
Bachelor's or Master's in closely-related field
2.

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":

3.

Please indicate if you possess any of the following certificates (check all that apply):

BLS
ACLS
PALS
National Certification (CCRN, etc.)
Preceptor Training Certificate
Critical Care Certificate
Other
 

If other was selected, identify the licenses and/or certificates.

4.

Please describe your experience as a Registered Nurse in an acute care hospital unit.  Include the following:

  1. Employer, and type of unit (ICU, PCU/step down, medical surgical, ER, etc)
  2. Job Title
  3. Dates of employment (from/to)
  4. Brief summary of the specific nursing duties performed