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#CCT-2320-900399
Supplemental Questionnaire

Last Name
First Name

 

2320 REGISTERED NURSE
SPECIALTY: NEONATAL INTENSIVE 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 Neonatal Intensive 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 Neonatal Intensive 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 a Level I or Level II Nursery AND I have a valid Certification in Neonatal Resuscitation Program AND I have a valid Certification in Basic Life Support.
I have completed a senior preceptorship in Infant Care AND I have a valid Certification in Neonatal Resuscitation Program AND I have a valid Certification in Basic Life Support.
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.

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 a Level I or Level II Nursery OR if you have not completed a senior preceptorship in Infant 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 these areas, type N/A.

2D.

If you have a valid Certification in Neonatal Resuscitation Program, please provide your name as it appears on your course completion card/certificate, the issue date, and the renewal date. If you do not have a valid Certification in Neonatal Resuscitation Program, please provide additional information below. 

2E.

If you have a valid Certification in Basic Life Support, please provide your name as it appears on your course completion card/certificate, the issue date, and the renewal date. If you do not have a valid Certification in Basic Life Support, please provide additional information below. 

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.

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

International Board Certified Lactation Consultant (IBCLC)
Neonatal Intensive Care Nursing (RNC-NIC) certification
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.

5.

Please indicate the total amount of experience you have working as a Registered Nurse in a Level I or Level II Nursery.

No experience
I have 12 months or less of experience working as a Registered Nurse in a Level I or Level II Nursery.
I have a total of 13 to 24 months of experience working as a Registered Nurse in a Level I or Level II Nursery.
I have a total of 25 to 36 months of experience working as a Registered Nurse in a Level I or Level II Nursery.
I have more than 36 months of experience working as a Registered Nurse in a Level I or Level II Nursery.
6.

Please indicate the total amount of experience you have working as a Registered Nurse in a Level III Nursery.

No experience
I have a total of 1 to 12 months of experience working as a Registered Nurse in a Level III Nursery.
I have a total of 13 to 24 months of experience working as a Registered Nurse in a Level III Nursery.
I have a total of 25 to 36 months of experience working as a Registered Nurse in a Level III Nursery.
I have more than 36 months of experience working as a Registered Nurse in a Level III Nursery.
7A.

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, II, and/or III Nursery.

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.

7B.

Please provide a brief description of your work experience as a Registered Nurse in a Level I, II, and/or III Nursery. 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.

8A.

Please indicate the total amount of experience you have as a Registered Nurse working with a culturally, socio-economically, and linguistically diverse patient population.

No experience
I have a total of 1 to 12 months of experience as a Registered Nurse working with a culturally, socio-economically, and linguistically diverse patient population.
I have a total of 13 to 24 months of experience as a Registered Nurse working with a culturally, socio-economically, and linguistically diverse patient population.
I have a total of 25 to 36 months of experience as a Registered Nurse working with a culturally, socio-economically, and linguistically diverse patient population.
I have more than 36 months of experience as a Registered Nurse working with a culturally, socio-economically, and linguistically diverse patient population.
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 as a Registered Nurse working with a culturally, socio-economically, and linguistically diverse patient 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.

8C.

Please provide a brief description of your work experience as a Registered Nurse working with a culturally, socio-economically, and linguistically diverse patient population. 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 training as a Registered Nurse in newborn hearing screening for both well and NICU neonates?

Yes No
9B.

If you have training as a Registered Nurse in newborn hearing screening for both well and NICU neonates, where did you obtain this training?

Alameda County Medical Center - Highland Hospital
Alta Bates Summit Medical Center
California Pacific Medical Center
Kaiser Permanente
Marin General Hospital
Mills-Peninsula Medical Center
St. Luke's Hospital
San Francisco General Hospital and Trauma Center
University of California, San Francisco (UCSF)
Other
I do not have training as a Registered Nurse in newborn hearing screening for both well and NICU neonates.
9C.

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

9D.

Please provide the name of your Employer(s)/Hospital(s)/Clinic(s) and the dates (e.g., MM/YYYY - MM/YYYY) you obtained your training as a Registered Nurse in newborn hearing screening for both well and NICU neonates.

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.

9E.

Please provide a brief description of your training as a Registered Nurse in newborn hearing screening for both well and NICU neonates. 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.