Official SealSan Joaquin County Human Resources Division


#0421-RH1104-TM
Supplemental Questionnaire

Last Name
First Name
1.

Have you completed the Adult and Pediatric Sexual Assault Training provided by the California Clinical Forensic Medical Training Center?  (Note: Training Certificate must be submitted by attachment to your application, by e-mail to alhandelman@sjgov.org or by fax ATTN: Andrea Handelman to (209) 468-0508)

Yes No
2.

License and Certificates:

Please list your current registration information as a nurse in the State of California.  Please include your license number and expiration date.

3.

Pattern I:

Do you have two (2) years of progressively responsible experience as a registered nurse in an acute care setting?

Yes No
 

If yes, please describe the duties you performed, your title, the name of the acute care institution you worked for, dates of employment and hours worked per week:

4.

Or, Pattern II:

Do you have a Bachelor's degree in Nursing, Health Science, or closely related field?  (If yes, please be sure that information is clearly noted on your employment application in the education section).

Yes No
5.
Do you have one (1) year of progressively responsible experience as a registered nurse in an acute care hospital?
Yes No
 

If yes, please describe the duties performed in the acute care hospital.  Please include the name of the acute care hospital you worked for, your title, dates of employment, and hours worked per week.