Official SealSan Joaquin County Human Resources Division


#0321-RH1104-T2
Supplemental Questionnaire

Last Name
First Name
1.

Are you currently licensed as a Registered Nurse with the State of California?

Yes No
 

If yes, please provide your license number below:

2.

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
3.

Do you possess at least two (2) years of paid registered nurse experience in an acute care facility that involved advanced nursing duties?

Yes No
 

If yes, please indicate your job title, employer, dates of employment and number of hours worked per week. Include in your answer a detailed description of the advanced clinical nursing duties you performed.

4.

Please mark the current certifications you possess. (Please Note: A copy of the certification(s) must be submitted with your employment application in order to be considered). Check all that apply:

ACLS Certification
PICC Certification
Chemotherapy Certification
PALS
NRP
Critical Care Course completion
ED Essentials Course completion
Preceptor
Wound Care
Other
5.

Do you possess National Certification? (Please Note, if yes, you must provide proof of certification with your employment application in order to be considered)

Yes No
6.

The Staff Nurse IV-Inp for the Float Pool department must be highly knowledgeable in many areas of acute care nursing. Please note all acute care areas you have direct nursing experience working in: (Check all that apply)

Medical/Surgical Unit
Intensive Care Unit (ICU)
Progressive Care Unit (2C/PCU)
Perioperative Services (Surgery/Recovery)
Emergency
Neonatal Intensive Care Unit (NICU)
FMC (Labor, Delivery,Post-Partum and Peds)
Dialysis
Float Pool Unit