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#CCT-2320-900400
Supplemental Questionnaire

Last Name
First Name

 

2320 REGISTERED NURSE
SPECIALTY: AMBULATORY 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 Ambulatory 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.

Which of the special conditions for a 2320 Registered Nurse in the Ambulatory Care Nursing specialty do you meet in order to qualify for this position?

I have at minimum one (1) year of verifiable experience (equivalent to 2,000 hours) within the last three (3) years as a Registered Nurse in an acute or urgent care, ambulatory care, or primary care clinical setting.
I have at minimum one (1) year of verifiable experience (equivalent to 2,000 hours) within the last three (3) years as a Registered Nurse in any setting AND documentation of successful completion of a preceptorship program in the Ambulatory Care setting.
I do not possess any of the above.
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 these areas, type N/A.

Note: If you do NOT possess a minimum of one (1) year of verifiable experience (equivalent to 2,000 hours) within the last three (3) years as a Registered Nurse in an acute or urgent care, ambulatory care, or primary care clinical setting OR a minimum one (1) year of verifiable experience (equivalent to 2,000 hours) within the last three (3) years as a Registered Nurse in any setting AND documentation of successful completion of a preceptorship program in the Ambulatory Care setting, 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 these areas, type N/A.

3A.

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 higher (e.g., PhD in Nursing)
None of the above
3B.

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

4A.

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

Certified Asthma Educator (AE-C)
Certified Diabetes Educator (CDE)
Public Health Nurse (PHN) certificate
None of the above
4B.

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.

5A.

Please indicate the total amount of experience you have working as a Registered Nurse in an acute or urgent care, ambulatory care, or primary care clinical setting.

No experience
I have worked 12 months or less as a Registered Nurse in an acute or urgent care, ambulatory care, or primary care clinical setting.
I have a total of 13 to 36 months of experience working as a Registered Nurse in an acute or urgent care, ambulatory care, or primary care clinical setting.
I have more than 36 months of experience working as a Registered Nurse in an acute or urgent care, ambulatory care, or primary care clinical setting.
5B.

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 acute or urgent care, ambulatory care, or primary care clinical setting.

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.

5C.

Please provide a brief description of your work experience as a Registered Nurse in an acute or urgent care, ambulatory care, or primary care clinical setting. Include in your answer your specific role and primary duties and responsibilities (e.g., charge nurse). If you do not have experience in these areas, type N/A.

6A.

Please indicate the total amount of experience you have as a Registered Nurse working in chronic disease management.

No experience
I have a total of 1 to 12 months of experience as a Registered Nurse working in chronic disease management.
I have a total of 13 to 36 months of experience as a Registered Nurse working in chronic disease management.
I have more than 36 months of experience as a Registered Nurse working in chronic disease management.
6B.

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 chronic disease management.

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.

6C.

Please provide a brief description of your work experience as a Registered Nurse working in chronic disease management. 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.

7A.

Please indicate the total amount of experience you have as a Registered Nurse working with an urban, poor, underserved population with chronic psychosocial and medical problems. 

Use this definition of psychosocial when answering the question: un- or underemployed, homeless or marginally housed, chronic mental health issues, incarcerated, exposure to trauma and violence, or substance abuse.

No experience
I have a total of 1 to 12 months of experience as a Registered Nurse working with an urban, poor, underserved population with chronic psychosocial and medical problems.
I have more than 12 months of experience as a Registered Nurse working with an urban, poor, underserved population with chronic psychosocial and medical problems.
7B.

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 with an urban, poor, underserved population with chronic psychosocial and medical problems.

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.

7C.

Please provide a brief description of your work experience as a Registered Nurse working with an urban, poor, underserved population with chronic psychosocial and medical problems. Include in your answer the specific location (e.g., San Francisco, CA) of the population you worked with. Also include your specific role and primary duties and responsibilities (e.g., charge nurse). If you do not have experience in this area, type N/A.

8A.

Have you successfully completed a residency or preceptorship in Medical-Surgical nursing, or a residency in Ambulatory nursing?

Yes No
8B.

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 in a residency or preceptorship in Medical-Surgical nursing or your experience in a residency in Ambulatory nursing.

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 these areas, type N/A.

8C.

Please provide a brief description of your residency or preceptorship in Medical-Surgical nursing or your residency in Ambulatory nursing. Include in your answer your specific role and primary duties and responsibilities. If you do not have experience in these areas, type N/A.

9A.

Which of these electronic medical records software have you used in your duties as a Registered Nurse? You may select more than one.

athenaClinicals
eClinicalWorks
EpicCare EMR
NextGen
Practice Fusion
Other
I do not have experience using electronic medical records in my duties as a Registered Nurse.
9B.

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

9C.

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 using electronic medical records software in your duties as a Registered Nurse.

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.

9D.

Please provide a brief description of your work experience using electronic medical records software in your duties as a Registered Nurse. 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.

10A.

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
10B.

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

11A.

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
11B.

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

12A.

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
12B.

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.