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#CCT-2320-900404
Supplemental Questionnaire

Last Name
First Name

 

2320 REGISTERED NURSE
SPECIALTY: PERINATAL 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 Perinatal 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 of verifiable experience (equivalent to 2,000 hours) as a Registered Nurse in Labor and Delivery and/or Postpartum WITHIN THE LAST THREE YEARS 

AND have a valid certification in the Neonatal Resuscitation Program issued by the American Academy of Pediatrics and the American Heart Association

AND have a valid Certification in Basic Life Support - Healthcare provider?

Yes.
Partially. I have some but NOT one year of experience working as a Registered Nurse in Labor and Delivery and/or Postpartum within the last three years.
Partially. I have at least one year of experience working as a Registered Nurse in Labor and Delivery and/or Postpartum within the last three years but I do NOT have both a valid certification in Neonatal Resuscitation Program and a valid Certification in Basic Life Support – Healthcare provider.
No. All of my work experience as a Registered Nurse in Labor and Delivery and/or Postpartum occurred more than three years ago.
No. I do not have at least one year of experience working as a Registered Nurse in Labor and Delivery and/or Postpartum and I do not have a valid Certification in Neonatal Resuscitation Program and/or a valid Certification in Basic Life Support – Healthcare provider.
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 Labor and Delivery and/or Postpartum, 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.

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 - Healthcare provider, 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 - Healthcare provider, please provide additional information below.

3A.

Please indicate the total amount of experience you have as a Registered Nurse in Labor and Delivery and/or Postpartum.

No experience
I have 12 months or less of experience as a Registered Nurse in Labor and Delivery and/or Postpartum.
I have a total of 13 to 24 months of experience as a Registered Nurse in Labor and Delivery and/or Postpartum.
I have a total of 25 to 36 months of experience as a Registered Nurse in Labor and Delivery and/or Postpartum.
I have more than 36 months of experience as a Registered Nurse in Labor and Delivery and/or Postpartum.
3B.

Please select the specific area(s) in which your experience in Labor and Delivery and/or Postpartum was obtained.

Postpartum only
Labor and Delivery only
Postpartum and Labor and Delivery
High Risk Postpartum Labor and Delivery
Charge RN in Postpartum Labor and Delivery
Charge RN in High Risk Postpartum Labor and Delivery
I do not have experience as a Registered Nurse working in the above areas.
3C.

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 Labor and Delivery and/or Postpartum.

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.

3D.

Please provide a brief description of your work experience as a Registered Nurse in Labor and Delivery and/or Postpartum. 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.

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)
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(s)/certificate(s) you possess. You may select more than one.

International Board Certified Lactation Consultant (IBCLC)
Obstetric Life Support (OBLS) certification
Registered Nurse, Certified in Inpatient Obstetrics (RNC-OB)
Registered Nurse, Certified in Maternal Newborn Nursing (RNC-MNN)
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.

Have you successfully completed an advanced fetal monitoring course within the last two years

Yes No
6B.

Please provide the name of your Employer(s)/Hospital(s)/Clinic(s) or the organization that provided the advanced fetal monitoring course. Include in your response the date (e.g., MM/YYYY) you completed the course.

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 the training/instruction you received in the advanced fetal monitoring course. If you have not completed this course, type N/A.

7A.

Do you have experience using electronic medical records software such as WatchChild or Lifetime Clinical Record (LCR) in your duties as a Registered Nurse in Labor and Delivery and/or Postpartum?

Yes No
7B.

If you have experience using electronic medical records software in your duties as a Registered Nurse in Labor and Delivery and/or Postpartum, 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 Labor and Delivery and/or Postpartum.
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 using electronic medical records software in your duties as a Registered Nurse in Labor and Delivery and/or Postpartum.

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 using electronic medical records software in your duties as a Registered Nurse in Labor and Delivery and/or Postpartum. 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.