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#CCT-2320-900412
Supplemental Questionnaire

Last Name
First Name

 

2320 REGISTERED NURSE
SPECIALTY: MEDICAL-SURGICAL 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 Medical-Surgical 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 working as a Registered Nurse in acute care WITHIN THE LAST THREE YEARS?

Yes.
Partially. I have some but NOT one year of experience working as a Registered Nurse in acute care within the last three years.
No. All of my work experience as a Registered Nurse in acute care occurred more than three years ago.
No. I do not have at least one year of experience as a Registered Nurse in acute care.
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 acute care, 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 acute care.

No experience
I have worked 12 months or less as a Registered Nurse in acute care.
I have a total of 13 to 36 months of experience as a Registered Nurse in acute care.
I have more than 36 months of experience as a Registered Nurse in acute care.
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 acute care.

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 acute care. 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 select the highest level of education you have completed.

Associate degree in Nursing (ASN/ADN)
Associate degree in Nursing (ASN/ADN) and currently enrolled in a BSN program
Bachelor of Science degree in Nursing (BSN)
Master of Science degree in Nursing (MSN)
None of the above
4B.

Please list the school(s) where you obtained your degree(s). If you have a ASN/ADN and are currently enrolled in a BSN program, list the name of the school you are attending. If you do not possess any of the degrees above, type N/A.

5A.

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

Certified medical-surgical (CMSRN)
Registered Nurse-Board Certified (RN-BC)
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.
I have a total of 13 to 36 months of experience working as a Registered Nurse in a Level I Trauma Center.
I have more than 36 months of experience working as a Registered Nurse in a Level I Trauma Center.
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 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 indicate the total amount of experience you have as a Registered Nurse working with a diverse urban population.

No experience
I have a total of 1 to 5 months of experience as a Registered Nurse working with a diverse urban population.
I have a total of 6 to 12 months of experience as a Registered Nurse working with a diverse urban population.
I have more than 12 months of experience as a Registered Nurse working with a diverse urban population.
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 a diverse urban population.

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 a diverse urban population. Include in your answer the specific location of the diverse urban population you worked with (e.g., San Francisco, CA). 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.

Do you have experience using electronic medical records software such as Invision in your duties as a Registered Nurse in an acute care setting?

Yes No
8B.

If you have experience using electronic medical records software in your duties as a Registered Nurse in an acute care setting, where did you obtain this experience?

Alameda County Medical Center - Highland Hospital
Alta Bates Summit Medical Center
California Pacific Medical Center
Kaiser Permanente
Marin General Hospital
Mills-Peninsula Medical Center
Saint Francis Memorial Hospital
San Francisco General Hospital and Trauma Center
Other
I do not have experience using electronic medical records software in my duties as a Registered Nurse in an acute care setting.
8C.

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

8D.

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 an acute care 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.

8E.

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

9A.

Do you have at least six months of case management experience in a healthcare facility?

The American Nurse Credentialing Center defines nursing case management as: "A collaborative approach to provide and coordinate health care services to a defined population which includes five components: Assessment, Planning, Implementation, Evaluation and Interaction

Nurse case managers participate with their clients to identify and facilitate options and services for meeting individuals' health needs, with the goal of decreasing fragmentation and duplication of care, and enhancing quality, cost-effective clinical outcomes."

Yes No
9B.

Please provide the name of your Employer(s)/Hospital(s)/Clinic(s) and the dates (e.g., MM/YYYY - MM/YYYY) you obtained your case management experience in a healthcare facility.

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.

9C.

Please provide a brief description of your case management experience in a healthcare facility. 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.