Official SealSan Joaquin County Human Resources Division


#0524-RH1163-TM
Supplemental Questionnaire

Last Name
First Name
1.

This position requires that you possess licensed Nurse Practitioner experience in the area in which you would be assigned. This position will be assigned to Neonatal Intensive Care Unit (NICU) and will require at least three (3) years Nurse Practitioner experience in a hospital NICU. If you possess this experience, please provide the name of your employer, dates of employment and a description of duties performed as a licensed Nurse Practitioner in the area noted.
2.

Have you completed an approved Nurse Practitioner training program at an accredited college or university, or another approved certified program? 
Yes No
 

Please provide the name, location, and dates completed of the certified program.
3.

Do you hold current registration as a Registered Nurse and current certification as a Nurse Practitioner in the State of California?
Yes No
 

Please provide your current Registered Nursing License # and your current Nurse Practitioner License #.
4.

Do you currently possess a furnishing license through the State of California, Board of Registered Nursing?
Yes No
5.

This position requires additional advanced education, certification or experience in an area of practice as approved by the San Joaquin Department of Health Care Services.  Please describe this education, certification, or experience: