Official SealSan Joaquin County Human Resources Division


#0321-RH1104-04
Supplemental Questionnaire

Last Name
First Name
1

Do you possess a Bachelor's degree in Nursing or a closely related field?

Please ensure that the information is clearly identified in the Education section of the employment application.
Yes No
2

In order to be eligible for the Staff Nurse IV in the Pediatric Unit, the following classes or courses, or certifications must have been successfully completed.  Please check all that apply:

Note: Please submit copies of all certifications with the completed employment application, or send via email to kparker@sjgov.org or fax to (209) 468-0508.
PALS
Preceptor Course or equivalent
National Certification
None of the above
3

Please identify the number of years of full-time (40 hours per week) paid RN experience in an acute care hospital's Pediatric Unit that you possess:
Less than 1 year of RN experience in an acute care Pediatric unit
1-2 years of RN experience in an acute care Pediatric unit
More than 2 years of RN experience in an acute care Pediatric unit
I do not possess any RN experience in an acute care Pediatric unit
4

Please provide your RN license number below: