Official SealSan Joaquin County Human Resources Division


#0422-RH1124-AC
Supplemental Questionnaire

Last Name
First Name
1.

Please mark any courses you have successfully completed. Check all that apply. (NOTE: Proof of completion must be submitted with your application in order for it to be considered)

EKG Course
ACLS
PALS
Preceptor Course or equivalent
I do not possess any of the certifications noted above
Other
 

If "Other", please name the certification:

2.

Education:

Do you possess either of the following? Check all that apply (Note: Proof of National Nursing Certification must be included with your application in order to be considered)

I possess a Bachelor's Degree in Nursing or closely related field. (Ensure all information regarding your degree is clearly noted in the Education portion of your application)
I possess National Nursing certification in my field of expertise
I do not possess a Bachelor's Degree in Nursing or related field or National Certification.
3.

Please note the number of years of experience you have as a Registered Nurse in an Acute Care Hospital setting at a level equivalent to Staff Nurse III in San Joaquin County:

2 years or more
1 - 2 years
6 months - 1 year
less than 6 months
I do not possess RN experience in an Acute Care Hospital Setting
 

Please describe your experience including the following:

  • Name of Employer
  • Job Title
  • Start and end dates of employment
  • Average number of hours worked per week