San Joaquin County Human Resources Division
#1021-RH1104-01
Supplemental Questionnaire
| Last Name | |
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| First Name |
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1. 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 |
| Does not apply |
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2. License: Provide your current RN License Number so that it can be source verified with the State of California Board of Registered Nursing. If you do not possess a valid or current RN License, please note "N/A": |
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3. The following section will be utilized to determine if you possess the license and/or certifications required to qualify as a Staff Nurse IV for a specific inpatient unit. Copies may be attached in your online application, emailed to alhandelman@sjgov.org, or faxed to (209) 468-0508, ATTN: Andrea Handelman. Please indicate if you possess any of the following certificates (check all that apply): |
| Preceptor Course |
| ACLS Certification |
| Critical Care Class |
| National Certification (CCEN, CCRN, CNN, CDN, CPAN, CNOR, PCCN) |
| Other |
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If other was selected, identify the licenses and/or certificates. |
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4. Please describe your experience as a Registered Nurse in an acute care hospital unit. Include the following:
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