Official SealSan Joaquin County Human Resources Division

Supplemental Questionnaire

Last Name
First Name

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

Yes No

If yes, please provide your license number below:



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

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.


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
Critical Care Course completion
ED Essentials Course completion
Wound Care

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

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)
Neonatal Intensive Care Unit (NICU)
FMC (Labor, Delivery,Post-Partum and Peds)
Float Pool Unit