Official SealSan Joaquin County Human Resources Division


#1219-RH1106-01
Supplemental Questionnaire

Last Name
First Name

 

Please complete the following supplemental questions for the position of Staff Nurse V-Assistant Nursing Department Manager in the Intensive Care Unit of San Joaquin General Hospital.  This supplemental will be utilized to best determine your qualifications for this position.


1.

Are you currently registered as a nurse in the State of California?

Yes No
 

If yes, please list your license number and expiration date:

2.

Do you possess either a Bachelor's Degree in Nursing or CCRN Certification? (NOTE: If yes, please ensure that you clearly note your degree in the education portion of your employment application. Proof of CCRN must be submitted with employment application in order to be considered). 

Yes No
 

If yes, please check all that apply:

Bachelor's Degree in Nursing or related field
CCRN Certification (proof must be attached with application to be considered)
I do not possess a BSN or CCRN
3.

Do you possess at least two (2) years of Intensive Care Unit experience including one (1) year equivalent to a Staff Nurse IV in San Joaquin County?

Yes No
 

If yes, please describe in detail the journey level nursing duties performed in the Intensive Care Unit.  Please include in your answer: whether or not you have supervised staff and conducted training in the Intensive Care Unit.

4.

In order to qualify for this position, candidates must have successfully completed all of the following: an approved Critical Care Course, Preceptor Course and ACLS certification.(NOTE: Proof of completion must be submitted with application in order to be considered).

Please verify the following (check all that apply):

Yes, I have successfully completed a Critical Care Course.
Yes, I have successfully completed a Preceptor course.
Yes, I have ACLS certification.
No, I have not completed any or all of the above mentioned courses/certification.