Official SealSan Joaquin County Human Resources Division


#0422-RH1106-AC
Supplemental Questionnaire

Last Name
First Name
1

Licenses & Certifications

Do you possess a current active license as a registered nurse from the California Board of Registered Nurses (CA BRN)?

Yes No
1a

If you responded yes, list your RN license below: 

2

The following courses/certifications are all required for the position of Staff Nurse V-ADM Inpatient for the Emergency Department. (NOTE: Copies of certifications and course completions must be submitted with your employment application in order to be considered). Please check all that apply:

I have completed an ED Essentials course or equivalent.
I have completed an MSE Triage course.
I have completed a Preceptor course or equivalent.
I have completed a PALS course.
I possess MICN-Code 3 clearance.
I possess current ACLS certification.
I do not possess any of the certifications noted above.
3

Please indicate the education completed and/or the national certification you possess below. Check all that apply.

Bachelor's degree in Nursing or related field.
CEN (Certified Emergency Nurse)
CCRN (Critical Care RN)
TNCC (Trauma Nursing Core Curriculum)
ENPC (Emergency Nurse Pediatric Course)
None of the above
4

Please indicate the total number of full-time (40 hours per week) paid RN experience you possess in an acute care hospital ER.

less than 1 year
more than 1 year but less than 3 years
more than 3 years but less than 5 years
I do not possess any full-time paid RN experience in an acute care hospital ER.
5

Please provide a detailed description of the specific duties performed as a RN in an acute care hospital ER.

6

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.