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#0820-RH1105-AC
Supplemental Questionnaire

Last Name
First Name
1

Licenses & Certificates:

Are you currently licensed as a registered nurse in the State of California?
Yes No
1a

Please provide your RN license number which will be source verified.

 
2

Please indicate if you possess the following:

 
Fetal Heart Monitoring Class
Advanced Fetal Heart Monitoring Class
Neonatal Resuscitation Program
Preceptor Class
National Certification
All of the above
None of the above
2a

If you indicated that you possess a national certification, please identify the type of certification and the certifying agency below.
3

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.
Bachelors degree - Nursing (BSN)
Masters degree - Nursing (MSN)
None of the above
3a

Please identify any course work completed in nursing education. Include school, course title, and number of units.
3b

Please describe your experience teaching. If no experience, please note "none".
4

EXPERIENCE

Do you possess at least two years of full-time paid RN experience in an acute care Family Maternity Center (FMC)?
Yes No
4a

If yes, describe the specific journey-level FMC duties performed.  Include the following:

  • Employer
  • Dates of Employment
  • Number of hours worked per week
4b

Describe your experience as a charge nurse or nursing supervisor.  If no experience, please indicate by noting "none".