Department of Human Resources

2320 REGISTERED NURSE
SPECIALTY: LONG TERM CARE/GERIATRIC NURSING
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 Training and Experience Evaluation, 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 sections 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. Responses should be consistent with the information on your employment application and are subject to verification. 

PART ONE: EXPERIENCE, LICENSES AND CERTIFICATION QUALIFICATIONS

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

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

As a reminder, all licenses, certifications and registrations must be listed in the "Professional Licenses, Certifications or Registrations" section of the application in order to receive credit for the licenses, certifications and registrations.  If you are copying an old application, please take the time to update the appropriate sections before submitting your application.

Do you have at least SIX months (equivalent to 1,000 hours) of nursing experience as a Registered Nurse, and/or LVN, and/or CNA in a skilled nursing facility, acute care setting, or in-patient rehabilitation or in-patient behavioral health setting WITHIN THE LAST THREE YEARS?

As a reminder, all work experience must be listed in the "Employment Record" section of the application in order to receive credit for this experience. If you are copying an old application, please take the time to update the appropriate sections before submitting your application.

PART TWO: TRAINING AND EXPERIENCE EVALUATION

INSTRUCTIONS 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.
• If you do not have experience that relates to the question(s) below, please enter “N/A” as your response.

Please indicate the total amount of experience you have working as a Registered Nurse, and/or LVN, and/or CNA in a skilled nursing facility.

Please indicate the total amount of experience you have working as a Registered Nurse, and/or LVN, and/or CNA in an acute care setting, in-patient rehabilitation, or in-patient behavioral health setting.

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, and/or LVN, and/or CNA in a skilled nursing facility, acute care setting, or in-patient rehabilitation or in-patient behavioral health 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 these areas, type N/A.

Please provide a brief description of your work experience as a Registered Nurse, and/or LVN, and/or CNA in a skilled nursing facility, acute care setting, or in-patient rehabilitation or in-patient behavioral health setting. 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.

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.

Please select the nursing procedure where you possess at least six months of experience as a Registered Nurse. You may select more than one.

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 in the nursing procedure(s) you selected in the above question.

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.

Please provide a brief description of your work experience as a Registered Nurse in the nursing procedure(s) you selected above. 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.

Please indicate the total amount of experience you have using an electronic medical record/charting system in your duties as a Registered Nurse, and/or LVN, and/or CNA.

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 an electronic medical record/charting system in your duties as a Registered Nurse, and/or LVN, and/or CNA.

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 using an electronic medical record/charting system in your duties as a Registered Nurse, and/or LVN, and/or CNA. 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 in preventing, managing, and de-escalating aggressive incidents (such as
SMART training) in an underserved urban population in a long term care setting?

If you have training in preventing, managing, and de-escalating aggressive incidents in an underserved urban population in a long term care setting, where did you obtain your experience? Select all that apply.

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 in preventing, managing, and de-escalating aggressive incidents in an underserved urban population in a long term 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 training in this area, type N/A.

Please provide a brief description of the training you received in preventing, managing, and de-escalating aggressive incidents in an underserved urban population in a long term care setting. 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."