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#CCT-2320-900320
Supplemental Questionnaire

Last Name
First Name

 

2320 REGISTERED NURSE
SPECIALTY: PERIOPERATIVE 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 Perioperative 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 Perioperative Nursing specialty do you meet in order to qualify for this position?

Note: Verifiable experience from successful completion of a Periop 101 clinical preceptorship in an operating room in an acute care hospital may be counted towards the experience needed to qualify for this position.

I have at minimum two (2) years of verifiable experience (equivalent to 4,000 hours) within the last three (3) years as a Registered Nurse in an operating room in an acute care hospital AND I am able to scrub and circulate.
I have at minimum six (6) months of verifiable experience (equivalent to 1,000 hours) as a Registered Nurse in an operating room in an acute care hospital within the last two (2) years AND I have a Certificate of completion of AORN Periop 101 AND I am able to scrub and circulate.
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. If you have a certificate of completion of AORN Periop 101, include in your answer where you completed your preceptorship.

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 two (2) years of verifiable experience (equivalent to 4,000 hours) within the last three (3) years as a Registered Nurse in an operating room in an acute care hospital OR a minimum of six (6) months of verifiable experience (equivalent to 1,000 hours) as a Registered Nurse in an operating room in an acute care hospital within the last two (2) years AND a Certificate of completion of AORN Periop 101, 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 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)
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.

Do you possess a valid CNOR certification?

Yes No
4B.

Please list your CNOR certificate ID. If applicable, include the expiration date. If you do not possess a valid CNOR certification, type N/A.

5A.

Please indicate the total amount of experience you have working as a Registered Nurse in an operating room in an acute care hospital.

No experience
I have 24 months or less of experience working as a Registered Nurse in an operating room in an acute care hospital.
I have more than 6 but less than 25 months of experience working as a Registered Nurse in an operating room in an acute care hospital AND I have a certificate of completion of AORN Periop 101.
I have a total of 25 to 36 months of experience working as a Registered Nurse in an operating room in an acute care hospital.
I have a total of 37 to 48 months of experience working as a Registered Nurse in an operating room in an acute care hospital.
I have a total of 49 to 60 months of experience working as a Registered Nurse in an operating room in an acute care hospital.
I have more than 60 months of experience working as a Registered Nurse in an operating room in an acute care hospital.
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 operating room in an acute care hospital.

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 operating room in an acute care hospital. 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.

6A.

Please use this definition of "scrub" when answering the following question: "Scrub" refers to the scrub role. In the scrub role, the Registered Nurse is responsible for maintaining a sterile field throughout the surgical procedure, passing instruments, sponges and other items requested by the surgeon.

How many times per month do you scrub as a Registered Nurse?

0 times/no experience
1 to 3 times per month
5 to 10 times per month
More than 10 times per month
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 the scrub role.

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 the scrub role. Include in your answer your specific duties and responsibilities (e.g., passing instruments). If you do not have experience in this area, type N/A.

7A.

Do you have experience as a Registered Nurse working in a Level I or Level II Trauma Center?

Yes No
7B.

If you have experience working as a Registered Nurse in a Level I or Level II Trauma Center, where did you obtain this experience? Select all that apply.

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
I do not have experience as a Registered Nurse working in a Level I or II Trauma Center.
7C.

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

7D.

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 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.

7E.

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.

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.