Department of Human Resources

2320 REGISTERED NURSE
SPECIALTY: PERINATAL CARE NURSING TRAINING PROGRAM
SUPPLEMENTAL QUESTIONNAIRE

All applicants are required to complete the Supplemental Questionnaire as part of the online application process. The questionnaire will be used to 1) assess each candidate's possession of the minimum qualifications; and 2) determine each candidate's score on the Supplemental Questionnaire Examination, as described on the examination announcement.

Responses to items on the Supplemental Questionnaire must be supported by the information provided on the application. This information is subject to verification. Please be sure to include all relevant education, professional licenses, certifications or registrations and work experience in the respective Education, Professional Licenses/Certifications/Registrations, and Employment Record section of the application.

Resumes are NOT used or reviewed to determine whether you meet the minimum qualifications or to determine your score/rank. A resume should not be submitted to substitute for a completed application. If you write “See Resume” on the application or on the Supplemental Questionnaire, your application may be rejected. Verification of experience, licensure, and possession of valid certifications/registrations may be collected at any time.

If you experience technical difficulties, make note of any error messages and contact the Analyst before the filing deadline. Responses should be consistent with the information on your employment application and are subject to verification.

PART ONE: EDUCATION, LICENSES AND CERTIFICATION QUALIFICATIONS

INSTRUCTIONS FOR QUESTIONS #1 - #2: Please answer all applicable questions by choosing the best response that matches your education, certifications, and licenses.

Do you possess a valid permanent/temporary (including interim permit) California Registered Nurse Licenses issues by the California Board of Registered Nursing?

As a reminder, all licenses must be listed in the application in order to be considered in review of Minimum Qualifications. If you do not include the license(s) you are about to describe in the "Professional Licenses, Certifications or Registrations" section of your application, you will not receive credit for the license(s). If you are copying an old application, please take the time to update your Education before submitting your application.

Have you successfully completed an Introduction to Fetal Heart Monitoring course within the last two years AND do you possess a valid certification in Basic Life Support - Healthcare provider?

As a reminder, all education, licenses, certifications and registrations must be listed in the application in order to be considered in review of Minimum Qualifications. If you do not include the education, licenses, certifications and registrations you are about to describe in the “Higher Education,” and "Professional Licenses, Certifications or Registrations" sections of your application, you will not receive credit for this education, licenses, certifications and registrations. If you are copying an old application, please take the time to update your Education and Licenses/Certifications/Registrations before submitting your application.

PART TWO: TRAINING AND EXPERIENCE EVALUATION

INSTRUCTION FOR QUESTIONS #3 - #12

• Review the questions first, prepare and save your responses in a word processing document, and then paste them into the online Supplemental Questionnaire.
• Be concise but thorough. Ensure that you address all parts of the question. Your written communication skills will be evaluated based on your responses.
• Ensure that your responses are sufficiently detailed to assist in evaluating your knowledge, skills and abilities.
• Provide your best or highest examples of work.
• Answer all questions independently (e.g., do not reference your responses in prior questions). Provide all information requested even if they appear redundant. Do not write “See Application” or “See Resume” as a response.

Please select the highest level of education you have completed.

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

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

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.

Have you successfully completed a senior preceptorship in Labor and Delivery or Postpartum?

Please provide the name of your Employer(s)/Hospital(s)/Clinic(s) and the dates (e.g., MM/YYYY - MM/YYYY) you completed your senior preceptorship in Labor and Delivery 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.

Please provide a brief description of your senior preceptorship in Labor and Delivery or Postpartum. Include in your answer your specific role and primary duties and responsibilities. If you do not have experience in this area, type N/A.

Have you successfully completed a Registered Nurse internship or residency in Labor and Delivery or Postpartum?

Please provide the name of your Employer(s)/Hospital(s)/Clinic(s) where you completed your Registered Nurse internship or residency in Labor and Delivery or Postpartum and the dates (e.g., MM/YYYY - MM/YYYY) you completed your internship or residency.

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.

Please provide a brief description of your Registered Nurse internship or residency in Labor and Delivery or Postpartum. Include in your answer your specific role and primary duties and responsibilities. If you do not have experience in these areas, type N/A.

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

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 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.

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

Do you have training as a Registered Nurse in newborn hearing screening for well neonates?

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

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

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 well 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.

Please provide a brief description of the training as a Registered Nurse in newborn hearing screening for well neonates that you received. If you do not have training in this area, type N/A.

Can you speak any of the following languages? You may select more than one.

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

Can you read any of the following languages? You may select more than one.

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

Can you write in any of the following languages? You may select more than one.

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

Please indicate how much verifiable experience you have working as a Registered Nurse in a general acute care hospital?  Pursuant to Title 22 CCR § 70005, General acute care hospital means a hospital, licensed by the Department, having a duly constituted governing body with overall administrative and professional responsibility and an organized medical staff which provides 24-hour inpatient care, including the following basic services: medical, nursing, surgical, anesthesia, laboratory, radiology, pharmacy, and dietary services. (Full Time is equivalent to 40 hrs/wk.)

Please provide the name of your Employer(s)/Hospital(s) and the dates (e.g., MM/YYYY - MM/YYYY) you obtained your experience as a Registered Nurse working in a general 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.

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

Do NOT type "See Resume."