Official SealSan Joaquin County Human Resources Division

Supplemental Questionnaire

Last Name
First Name

Licenses & Certificates:

Are you currently licensed as a registered nurse in the State of California?

Yes No

Do you possess a Bachelor's Degree in Nursing? (Please Note: If yes, be sure to clearly identify your degree either on the education portion of your employment application or resume as it will be source verified).

Yes No

Do you possess National Certification? (A copy of your certification must be submitted with employment application in order to be considered)

Yes No

Do you possess two (2) years of paid registered nurse experience in an acute care Medical/Surgical Department, including one (1) year at a level equivalent to Staff Nurse IV?

If yes please be sure to complete the Experience portion of the application in as much detail as possible. 

Yes No


Please mark active certifications that you currently possess: (Check all that apply)

Chemotherapy Certification
Preceptor or Adult Trainer Course Completion
I currently do not possess any of the certifications noted above

Positions in the Medical Guarded Unit provide health care services to an inmate population:

As a condition of employment, candidates must successfully pass a California Department of Corrections (CDCR) background investigation conducted by the California Department of Corrections and Rehabilitation.  Candidates must also maintain their CDCR clearance for continued employment in the Special Care Unit or Medical Guarded Inpatient Unit. Please check the below box to acknowledge you understand the above terms.

Yes, I acknowledge and understand the above terms.
I am not interested in being referred to the Medical Guarded Unit.