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#0821-RH1105-02
Supplemental Questionnaire

Last Name
First Name
1

Licenses & Certificates:

Are you currently licensed as a registered nurse in the State of California?
Yes No
 

If yes, please list the license number and expiration date.
2

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
3

The following courses/certifications are all required for the position of Staff Nurse V-Clinical Inpatient in Cardiology/Cardiac Catheter Lab. (NOTE: Copies of certifications and course completions must be submitted with your employment application in order to be considered). 

Please check all that apply:
I have completed an EKG class
I have completed a Preceptor Class (or adult educator/trainer equivalent).
I have current ACLS certification
I do not possess any of the certifications noted above.
4

How many years of paid, progressively responsible registered nurse experience do you possess in an acute care Cardiology unit or Cardiac Catheter lab?
I do not have experience in an acute care Cardiology unit or Cardiac Catheter Lab
1 - 2 years
2 - 3 years
More than 3 years
 

If yes, describe in detail your journey-level Cardiac unit duties below.  Please include in your response: name of employer, job title, dates of employment and number of hours worked per week.
5

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