Official SealDepartment of Human Resources


#CCT-2320-900422
Supplemental Questionnaire

Last Name
First Name

 

2320 REGISTERED NURSE
SPECIALTY: CRITICAL 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 Critical 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 ONE year (equivalent to 2,000 hours) of experience as a Registered Nurse in an Adult Medical/Surgical ICU with at least six (6) beds WITHIN THE LAST THREE YEARS?

Yes.
Partially. I have some, but NOT one year, of experience working as a Registered Nurse in an Adult Medical/Surgical ICU with at least six (6) beds within the last three years.
No. All of my experience as a Registered Nurse in an Adult Medical/Surgical ICU with at least six (6) beds occurred more than three years ago.
No. I do not have experience as a Registered Nurse in an Adult Medical/Surgical ICU with at least six (6) beds.
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 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 Adult Medical/Surgical ICU with at least six (6) beds, please still provide the information requested 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 Adult Medical/Surgical ICU with at least six (6) beds.

No experience
I have worked 12 months or less as a Registered Nurse in an Adult Medical/Surgical ICU with at least six (6) beds.
I have a total of 13 to 24 months of experience working as a Registered Nurse in an Adult Medical/Surgical ICU with at least six (6) beds.
I have a total of 25 to 36 months of experience working as a Registered Nurse in an Adult Medical/Surgical ICU with at least six (6) beds.
I have more than 36 months of experience working as a Registered Nurse in an Adult Medical/Surgical ICU with at least six (6) beds.
3C.

Please provide a brief description of your work experience as a Registered Nurse in an Adult Medical/Surgical ICU with at least six (6) beds. 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.

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 Adult Medical/Surgical ICU with at least six (6) beds.

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.

4A.

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
4B.

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

5A.

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

Advanced Burn Life Support (ABLS) certificate
Advanced Cardiovascular Life Support (ACLS) Course Completion card/certificate
Certified Neuroscience Registered Nurse (CNRN)
Critical care nurse for adult, pediatric and neonatal populations (CCRN) certification
Pediatric Advanced Life Support (PALS) Provider Course Completion card/certificate
Trauma Nurse Core Curriculum (TNCC) certificate
None of the above
5B.

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.

6A.

Please indicate the total amount of experience you have working as a Registered Nurse in a Level I Trauma Center as verified by the American College of Surgeons (ACS).

No experience
I have a total of 1 to 12 months of experience working as a Registered Nurse in a Level I Trauma Center as verified by the American College of Surgeons (ACS).
I have a total of 13 to 48 months of experience working as a Registered Nurse in a Level I Trauma Center as verified by the American College of Surgeons (ACS).
I have more than 48 months of experience working as a Registered Nurse in a Level I Trauma Center as verified by the American College of Surgeons (ACS).
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 in a Level I 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.

6C.

Please provide a brief description of your work experience as a Registered Nurse in a Level I 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.

7A.

Please select the following where you possess at least six months (equivalent to 1,000 hours) of experience as a Registered Nurse. You may select more than one.

Advanced neuromonitoring technologies experience
Charge nurse/preceptor experience
Code Blue Team participation
Continuous renal replacement therapy (CRRT) experience
Intra-aortic balloon pump (IABP) experience
Pediatric ICU experience
Performance improvement experience
Rapid Response Team participation
None of the above
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 for the response(s) you selected above.

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 any of the above areas, type N/A.

7C.

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

8A.

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
8B.

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

9A.

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
9B.

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

10A.

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
10B.

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.