Official SealSan Joaquin County Human Resources Division


#0723-RH1106-AC
Supplemental Questionnaire

Last Name
First Name
1.

Do you possess a current registration as a nurse in the State of California? if yes, please be sure to include your license number where requested on the application.
Yes No
2.

The following courses/certifications are all required for the position of Staff Nurse V-Clinical Inpatient for the Emergency Department. (NOTE: Copies of certifications and course completions must be attached to your employment application in order to be considered). Please check all that apply:
Yes, I have completed an ED Essentials Course or equivalent. (attach certificate of completion to application)
Yes, I have completed an MSE Triage Course. (attach certificate of completion to application)
Yes, I have completed a Preceptor Course or equivalent. (attach certificate of completion to application)
Yes, I have completed a PALS Course. (attach certificate of completion to application)
Yes, I possess MICN-Code 3 Clearance. (attach certificate of completion to application)
Yes, I possess current ACLS Certification. (attach certificate of completion to application)
No, I do not possess any of the certifications noted above.
3.

Please note the education and national certification that you possess below. Education must clearly be annotated on your employment application. A copy of your National Certification must be submitted with your employment application in order to be considered. Please check all that apply:
Yes, I possess a Bachelor's of Science Degree in Nursing or related field.
Yes, I possess National Certification.
I do not possess a Bachelor's Degree in Nursing or National Certification.
4.

Do you possess at least 3 years of paid journey-level RN experience in a large acute care hospital's Emergency Department including one year equivalent to a SN IV at San Joaquin County? If yes, please ensure that the employment history portion of the application is completed in detail.
Yes No