Official SealSan Joaquin County Human Resources Division


#0320-RH1102-01
Supplemental Questionnaire

Last Name
First Name
1.

Current registration as a nurse in the State of California or possession of an interim permit issued by the State of California Board of Nursing is required.

Please indicate below your RN or Interim Permit license number. Note: Your license will be verified with the State of California Board of Nursing.

2.

Employment in the San Joaquin County Department of Health Care Services (San Joaquin General Hospital) as a Student Nursing Assistant, Nursing Assistant or Licensed Vocational Nurse during enrollment in a registered nurse training program is required.

Are you currently or have you held one of the positions listed above at San Joaquin General Hospital while enrolled in a registered nurse training program?

Yes No
 

If you answered yes to question 2, please provide the below information. Number your responses accordingly:

  1. Name of Department employment was/is held;
  2. Job Title held;
  3. Dates of Employment (MM/DD/YY to MM/DD/YY);
  4. Name of school where enrolled/completed Registered Nurse Training Program;
  5. Dates enrolled in Registered Nurse Training Program (MM/DD/YY to MM/DD/YY).

Note: Please submit a copy of your Registered Nurse Training Program transcript along with your employment application by uploading it to the resume section on your online application or fax a copy to (209) 468-0508.  Proof of enrollment/program completion is required. 

 

3.

Position(s) may rotate or be assigned to the Medical Guarded Unit. As a condition of employment, candidates assigned to the Medical Guarded Unit must successfully pass a California Department of Corrections (CDCR) background investigation conducted by the California Depatment of Corrections and Rehabilitation.  Candidates must also maintain their CDCR clearance for continued employment in this unit. Please check the below box to acknowledge you understand the above terms.

Yes, I acknowledge and understand the above terms.