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#0321-RH1812-AC
Supplemental Questionnaire

Last Name
First Name
1.

This position requires a valid license as a Registered Nurse issued by the State of California Board of Registered Nursing.  Please provide your license number and expiration date.

2.

This position requires posession of a California State Public Health Nursing Certificate.  Please provide your certificate number and expiration date.


 

If required by the nature of the assignment, this position also requires possession of a valid California Driver License.


3.

To qualify for this position, you must have two years of post-bachelor's degree, community-based nursing experience in a community health, public school, county public health, or comparable setting that included work in areas such as communicable disease response/prevention, health education, public health emergency planning, or community-based nursing case management.  Please detail your experience and include the name of your employer, dates of employment, and job title.  If experience was part-time, please include hours worked per week.