Official SealSan Joaquin County Human Resources Division

Supplemental Questionnaire

Last Name
First Name


Please complete the following supplemental questions for the position of Staff Nurse V-Clinical Inpatient Nurse in the Intensive Care Unit of San Joaquin General Hospital.  This supplemental will be utilized to best determine your qualifications for this position.


Provide your registered nurse license number so that it can be source verified with the California Board of Registered Nursing. If you do not currently possess an RN license with the State of California, please write, "N/A".


Do you possess either a Bachelor's Degree in Nursing or CCRN Certification? (NOTE: If yes, please ensure that you clearly note your degree in the education portion of your employment application. Proof of CCRN must be submitted with employment application in order to be considered). 

Yes No

If yes, please check all that apply:

Bachelor's Degree in Nursing or related field
CCRN Certification (proof must be attached with application to be considered)
I do not possess a BSN or CCRN

Do you possess at least two (2) years of progressively responsible paid registered nurse experience in an Intensive Care Unit which included one (1) year equivalent to a Staff Nurse IV in San Joaquin County?

Yes No

If yes, please describe in detail the journey level nursing duties performed in the Intensive Care Unit.  Please include in your answer: whether or not you have supervised and/or trained nursing staff.


Please describe your experience as it specifically relates to being a clinical educator. Include in your answer the staff you educated, your precepting approaches, and how you monitored the success of the staff you guided. 


In order to qualify for this position, candidates must have successfully completed all of the following: an approved Critical Care Course, Preceptor Course and ACLS certification.(NOTE: Proof of completion must be submitted with application in order to be considered).

Please verify the following (check all that apply):

Yes, I have successfully completed a Critical Care Course.
Yes, I have successfully completed a Preceptor course.
Yes, I have ACLS certification.
No, I have not completed any or all of the above mentioned courses/certification.