Official SealSan Joaquin County Human Resources Division


#0821-RH1123-TM
Supplemental Questionnaire

Last Name
First Name
1.

Licenses & Certificates:

Are you currently licensed as a registered nurse in the State of California?
Yes No
 

If yes, please list the license number and expiration date. If no, please indicate if you have an interim permit issued by the State of California Board of Registered Nursing and note the IP number.
2.

Experience:

Do you possess 6 months paid experience as a registered nurse in an acute care or mental health facility? (Please note that nursing experience at a Skilled Nursing Facility is not recognized as acute care)
Yes No
 

If yes, please list the following: Name of employer, dates of employment, hours per week worked and the duties you performed as a registered nurse in an acute care environment.
3.

If you have experience as a registered nurse in an outpatient setting such as an Emergency Department or Acute Care Clinic, please describe the registered nurse duties you performed, services provided and the average daily patient volume of the department or clinic.
4.

Do you possess a Bachelor's Degree in Nursing?

Note: If yes, please be sure to clearly reflect that information on your employment application in the "education" section.
Yes No