Official SealSan Joaquin County Human Resources Division


#0919-RH1106-01
Supplemental Questionnaire

Last Name
First Name

 

Copies of all licenses and certifications must be submitted with the completed employment application. Failing to provide the required documents may result in a failure to move forward in the selection and hiring process. Copies of licenses and certifications may be submitted in the online application ("Other" tab), emailed to jripp@sjgh.org, or faxed to (209) 468-6271. All relevant RN experience should be included in the application.
1

Please provide your RN license number:
2

EDUCATION

Please indicate if you possess the following degree(s) from an accredited college/university.

This information should be clearly identified in the Education section of the employment application.
Associates degree - Nursing (ADN)
Bachelors degree - Nursing (BSN)
Masters degree - Nursing (MSN)
Other (clearly identify the degree and discipline in the Education portion of the application)
None of the above
3

Please indicate if you possess any of the following certificates (select all that apply):
ACLS
BLS
PALS
Preceptor course or Nursing Trainer certificate
Chemotherapy certificate
EKG class
PICC
National Certification
Other
None of the above
 

If "Other" was selected, identify the licenses and/or certificates that you possess.
4

Please identify the number of years that you possess of full-time (40 hours per week) paid RN experience in an acute care hospital.
less than 6 months
more than 6 months but less than 1 year
more than 1 year but less than 3 years
more than 3 years
I do not possess any RN experience in an acute care hospital
5

Please provide a brief description of your RN experience in an acute care hospital Medical Surgical Unit.  Include the following:

  1. Acute Care Hospital
  2. Dates of employment (from/to)
  3. Number of hours worked per week
  4. Specific duties and responsibilities
6

Note: Candidates hired in some units must successfully pass a California Department of Corrections and Rehabilitation (CDCR) background investigation and must maintain their clearance for continued employment.

Please indicate if you have read and understand this condition of employment.
Yes No