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#CCT-2320-900387
Supplemental Questionnaire

Last Name
First Name

 

2320 REGISTERED NURSE
SPECIALTY: EMERGENCY CARE NURSING
SUPPLEMENTAL QUESTIONNAIRE

The purpose of this Supplemental Questionnaire is to determine whether you meet the required licensure and special conditions of a 2320 Registered Nurse in the Emergency Care Nursing specialty as well as to determine your knowledge, skills and abilities in job-related areas that have been identified as critical for satisfactory performance in this position.

The information provided should be consistent with the information on your application and is subject to verification. Verification of experience, licensure, and possession of valid certifications/certificates may be collected at any time during or after the selection process so please choose the best answer for the questions below.


1A.

Do you possess a valid permanent/temporary (including interim permit) California Registered Nurse License issued by the California Board of Registered Nursing?

Yes No
1B.

If you answered "Yes" to Question 1A, please provide your California Registered Nurse license number, your name as it appears on your RN license, and the expiration date of your license. If you answered "No" to Question 1A, please provide additional information below. 

2A.

Do you have at least TWO years (equivalent to 4,000 hours) of experience working as a Registered Nurse in an Emergency Department WITHIN THE LAST THREE YEARS?

Yes
Partially. I have some, but NOT two years, of experience working as a Registered Nurse in an Emergency Department within the last three years.
No. All of my work experience as a Registered Nurse in an Emergency Department occurred more than three years ago.
No. I do not have experience working as a Registered Nurse in an Emergency Department.
2B.

Please provide the name of your Employer(s)/Hospital(s)/Clinic(s) and the dates (e.g., MM/YYYY - MM/YYYY) you obtained the experience that meets the special condition that qualifies you for this position.

In addition, please list the name of a supervisor or manager who can verify the information you provided as well as his or her contact information. If you do not have experience in this area, type N/A.

Note: If you do NOT possess a mminimum of two (2) years of verifiable experience (equivalent to 4,000 hours) within the last three (3) years as a Registered Nurse in an Emergency Department, please still provide the information requested above as well as the Registered Nurse experience you do possess.

2C.

Please provide a brief description of your work experience that meets the special condition that qualifies you for this position. Include in your answer your specific role and primary duties and responsibilities (e.g., charge nurse). If you do not have experience in this area, type N/A.

3A.

Please indicate the total amount of experience you have working as a Registered Nurse in an Emergency Department.

No experience
I have worked 24 months or less as a Registered Nurse in an Emergency Department.
I have a total of 25 to 36 months of experience working as a Registered Nurse in an Emergency Department.
I have a total of 37 to 48 months of experience working as a Registered Nurse in an Emergency Department.
I have a total of 49 to 60 months of experience working as a Registered Nurse in an Emergency Department.
I have more than 60 months of experience working as a Registered Nurse in an Emergency Department.
3B.

Please provide the name of your Employer(s)/Hospital(s)/Clinic(s) and the dates (e.g., MM/YYYY - MM/YYYY) you obtained your experience as a Registered Nurse in an Emergency Department.

In addition, please list the name of a supervisor or manager who can verify the information you provided as well as his or her contact information. If you do not have experience in this area, type N/A.

3C.

Please provide a brief description of your work experience as a Registered Nurse in an Emergency Department. Include in your answer your specific role and primary duties and responsibilities (e.g., charge nurse). If you do not have experience in this area, type N/A.

4A.

Please indicate the total amount of experience you have working as a Registered Nurse in one or more Level I or Level II Trauma Centers (that have been so designated and verified by the American College of Surgeons) within the last three years.

No experience
I have a total of 1 to 11 months of experience working as a Registered Nurse in one or more Level I or Level II Trauma Centers.
I have a total of 12 to 23 months of experience working as a Registered Nurse in one or more Level I or Level II Trauma Centers.
I have a total of 24 to 35 months of experience working as a Registered Nurse in one or more Level I or Level II Trauma Centers.
I have 36 months or more of experience working as a Registered Nurse in one or more Level I or Level II Trauma Centers.
4B.

If applicable, please indicate the Level I or Level II Trauma Center location where you worked as a Registered Nurse during the last three years.

Sutter Medical Center Castro Valley (Level II, Castro Valley)
NorthBay Medical Center (Level II, Fairfield)
Doctor’s Medical Center (Level II, Modesto)
Memorial Medical Center (Level II, Modesto)
Alameda County Medical Center (Level II, Oakland)
Children’s Hospital & Research Center (Level 1 Pediatric, Oakland)
San Francisco General Hospital and Trauma Center (Level 1, San Francisco)
Regional Medical Center of San Jose (Level II, San Jose)
Santa Clara Valley Medical Center (Level I, Level II Pediatric, San Jose)
Santa Rosa Memorial Hospital (Level I, Santa Rosa)
Stanford University Medical Center (Level I, Stanford)
Stanford Hospital and Clinics (Level 1 Pediatric, Stanford)
John Muir Medical Center (Level II, Walnut Creek)
Other
Does not apply. I have not worked in a Level I or II Trauma Center within the last 3 years.
4C.

If you selected "Other", please specify in the space below. Otherwise, type N/A.

4D.

Please provide the name of your Employer(s)/Hospital(s)/Clinic(s) and the dates (e.g., MM/YYYY - MM/YYYY) you obtained your experience as a Registered Nurse working in a Level I or Level II Trauma Center.

In addition, please list the name of a supervisor or manager who can verify the information you provided as well as his or her contact information. If you do not have experience in this area, type N/A.

4E.

Please provide a brief description of your work experience as a Registered Nurse in a Level I or Level II Trauma Center. Include in your answer your specific role and primary duties and responsibilities (e.g., charge nurse). If you do not have experience in this area, type N/A.

5A.

Please select the highest level of education you have completed.

Associate degree in Nursing (ASN/ADN)
Bachelor of Science degree in Nursing (BSN)
Master of Science degree in Nursing (MSN) or Master's degree from a graduate school of Nursing
None of the above
5B.

Please list the school(s) where you obtained your degree(s). If you do not possess any of the degrees above, type N/A.

6A.

Please select the valid certification(s)/certificate(s) you possess. You may select more than one.

Certification for Adult, Pediatric and Neonatal Critical Care Nurses (CCRN)
Certified Emergency Nurse (CEN)
Emergency Nursing Pediatric Course (ENPC) certificate
Pediatric Advanced Life Support (PALS) Provider Course Completion card/certificate
Trauma Nurse Core Curriculum (TNCC) certificate
None of the above
6B.

Please list the name of the agency(s) that issued the certification(s)/certificate(s) you possess. If applicable, include the expiration date.

If you do not possess any of the certifications/certificates listed above, type N/A.

7A.

Can you speak any of the following languages? You may select more than one.

Arabic
American Sign Language
Burmese
Cambodian
Chinese (Cantonese)
Chinese (Other)
Chinese (Mandarin)
Japanese
Korean
Laotian
Russian
Spanish
Tagalog (Philippines)
Vietnamese
Other
None of the above
7B.

If you selected "Other", please specify in the space below. Otherwise, type N/A.

8A.

Can you read any of the following languages? You may select more than one.

Arabic
American Sign Language
Burmese
Cambodian
Chinese (Cantonese)
Chinese (Other)
Chinese (Mandarin)
Japanese
Korean
Laotian
Russian
Spanish
Tagalog (Philippines)
Vietnamese
Other
None of the above
8B.

If you selected "Other", please specify in the space below. Otherwise, type N/A.

9A.

Can you write in any of the following languages? You may select more than one.

Arabic
American Sign Language
Burmese
Cambodian
Chinese (Cantonese)
Chinese (Other)
Chinese (Mandarin)
Japanese
Korean
Laotian
Russian
Spanish
Tagalog (Philippines)
Vietnamese
Other
None of the above
9B.

If you selected "Other", please specify in the space below. Otherwise, type N/A.

 

I certify that I am the author of this form and that all the information presented is true and based upon my experience. I understand that prior to an appointment I may be required to provide written verification of any of the information provided above and that I may be required by the hiring department to participate in performance test(s) during the probationary period. I further understand that any false, incomplete, or incorrect statement may result in disqualification, dismissal, or termination of employment with the City and County of San Francisco.