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

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


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

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.

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.


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.