Official SealSan Joaquin County Human Resources Division


#1021-RH1104-A4
Supplemental Questionnaire

Last Name
First Name
1.

Licenses & Certificates:

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

If yes, please list the license number and expiration date.
2.

Please indicate if you possess any of the following certificates (select all that apply):
Neonatal Resuscitation Program
ICN Class
Preceptor class or equivalent
National Certification
Other
None of the above
3.

Education:

Please indicate if you possess the following degree(s) from an accredited college/university.

NOTE: This information should be clearly identified in the Education section of the employment application.
Associates degree - Nursing (ADN)
Bachelor's degree - Nursing (BSN)
Master's degree - Nursing (MSN)
Other (Clearly identify the degree and discipline in the Education portion of your application)
None of the above
4.

Provide a brief description of your RN Neonatal Intensive Care Nursery experience.  Include the following in your response:

  • Acute Care Hospital
  • Dates of Employment
  • Number of hours worked per week
  • Specific duties and responsibilities