Official SealSan Joaquin County Human Resources Division


#1021-RH1106-AC
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.
2.

Do you possess two (2) years of paid registered nurse experience in an acute care Progressive Care Unit?
Yes No
 

If yes, please indicate your job title, employer, dates of employment and hours per week worked. Include in your answer a detailed description of the advanced administrative and/or clinical nursing duties you performed.
3.

Do you possess a Bachelor's Degree in Nursing? (Please Note: If yes, be sure to clearly identify your degree either on the education portion of your employment application or resume as it will be source verified).
Yes No
4.

Do you possess National Certification? (A copy of your certification must be submitted with employment application in order to be considered)
Yes No
6.

Certifications:

Please mark active certifications that you currently possess: (Check all that apply)
BLS Certification
ACLS Certification
PALS Certification
Chemotherapy Certification
EKG Certification or Course Completion
CCRN - Critical Care Nurse National Certification
Preceptor or Adult Trainer Course Completion
I currently do not possess any of the certifications noted above
7.

Please describe your experience as a charge nurse or nursing supervisor. Include in your response the number of staff supervised and how you monitored their performance.
 

*As a condition of employment, candidates must successfully pass a California Department of Corrections (CDCR) background investigation conducted by the California Department of Corrections and Rehabilitation. Please check the below box to acknowledge you understand the above terms.
Yes, I acknowledge and understand the above terms.