Official SealSan Joaquin County Human Resources Division


#0821-RH1124-01
Supplemental Questionnaire

Last Name
First Name
1.

Licenses:

Provide your current RN License Number so that it can be source verified with the State of California Board of Registered Nursing. If you do not possess a valid or current RN License, please note "N/A".
2.

Do you possess a Bachelor's Degree in Nursing or closely related field? (If, yes, please be sure to clearly indicate the status of your degree in the "education" portion of your employment application.)
Yes No
3.

National Nursing Certification(s):

Do you possess any of the following National Nursing Certifications? (Check All that Apply; Proof certifications(s) must be submitted with employment application.)
CCRN
TNCC
ENPC
CNOR
CPAN
CNN
CDN
CEN
I do not possess National Nursing Certification
4.

I possess the following number of years of licensed Registered Nurse experience in an acute care hospital. (Employer, Dates of Employment, number of hours per week worked, and nursing duties must clearly be defined in the “experience” portion of your employment application and/or resume).
1 year of paid RN experience
2-4 years of paid RN experience
5 or more years of paid RN experience
I possess less than 1 year of paid RN experience
5.

Please use this section to share your paid RN experience participating in skill fairs, community outreach, and continuing education in a clinical environment.
6.

Special Requirement:

Working in Ambulatory Care Services requires that you successfully complete one of the following within the first year of employment. (Course certification will be dependent upon which clinic an employee is assigned to):

1. EKG Class

2. ACLS

3. PALS

4. Chemotherapy Certification (for employees assigned to ID/Oncology Clinics)

Please check all that apply:
I have already completed an approved EKG Class. (Attach proof of completion with application).
I currently possess an active ACLS Certification Card. (Attach proof of completion with application).
I have already completed an approved PALS Class. (Attach proof of completion with application).
I currently possess active Chemotherapy Certification. (Attach proof of completion with application).
I understand that I must successfully complete one or more of the above mentioned courses/certifications within the first year of employment.