Official SealSan Joaquin County Human Resources Division


#0125-RH1106-AC
Supplemental Questionnaire

Last Name
First Name

 

You are applying for a position in Correctional Health Services, which provides health care to adult inmates at the San Joaquin County jail facility.

A candidate must successfully pass the security clearance, initiated through a background investigation conducted by the Sheriff’s Office. The background investigation requires the completion of an extensive questionnaire called “Personal History Questionnaire” and is used by the Sheriff’s Office to conduct the background investigation. 

The security clearance is a mandatory condition of employment, and the loss of the security clearance could result in termination from County employment in accordance with the rules and regulations governing County employment.


1.

Have you read the above information and understand that passing and maintaining a security clearance is a condition of employment?
Yes No
2.

Are you willing to work with adult inmates who are incarcerated?
Yes No
3.

Are you currently registered as a nurse with the State of California Board of Registered Nursing?
Yes No
3a.

If you answered yes, please provide your RN license number.
4.

Do you have three years of experience as a registered nurse in an acute correctional health or mental health facility equivalent to a San Joaquin County Staff Nurse IV?
Yes No
4a.

If yes, please identify the following:

  • Name of employer (hospital or medical/correctional facility)
  • Job title
  • Dates of employment
  • Typical duties
  • Hours worked per week

 
5.

Substitution:  Possession of a Bachelor’s Degree in Nursing may be substituted for one year of the required experience. Do you posses a Bachelor’s Degree in Nursing?
Yes No
5a.

If you answered "Yes" to the previous question, please provide the name of the school attended, degree obtained and the month and year of graduation.