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#CCT-2320-900429
Supplemental Questionnaire

Last Name
First Name

 

2320 REGISTERED NURSE
SPECIALTY: LONG TERM CARE/GERIATRIC 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 Long Term Care/Geriatric 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 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?

Yes.
Partially. I have some but NOT six months of experience working 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.
No. All of my 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 occurred more than three years ago.
No. I do not have at least six months of experience working 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.
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 this area, type N/A.

Note: If you do NOT possess a minimum of SIX months (equivalent to 1,000 hours) of nursing experience within the last three (3) years 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, please still provide the information requested above as well as the Registered Nurse, and/or LVN, and/or CNA 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 this area, type N/A.

3A.

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.

No experience
I have worked 6 months or less as a Registered Nurse, and/or LVN, and/or CNA in a skilled nursing facility.
I have a total of 7 to 12 months of experience as a Registered Nurse, and/or LVN, and/or CNA in a skilled nursing facility.
I have a total of 13 to 18 months of experience as a Registered Nurse, and/or LVN, and/or CNA in a skilled nursing facility.
I have more than 18 months of experience as a Registered Nurse, and/or LVN, and/or CNA in a skilled nursing facility.
3B.

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.

No experience
I have worked 6 months or less as a Registered Nurse, and/or LVN, and/or CNA in an acute care setting, or in-patient rehabilitation or in-patient behavioral health setting.
I have a total of 7 to 12 months of experience as a Registered Nurse, and/or LVN, and/or CNA in an acute care setting, or in-patient rehabilitation or in-patient behavioral health setting.
I have a total of 13 to 18 months of experience as a Registered Nurse, and/or LVN, and/or CNA in an acute care setting, or in-patient rehabilitation or in-patient behavioral health setting.
I have more than 18 months of experience as a Registered Nurse, and/or LVN, and/or CNA in an acute care setting, or in-patient rehabilitation or in-patient behavioral health setting.
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, 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.

3D.

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.

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.

Advanced Cardiovascular Life Support (ACLS)
Certified Hospice and Palliative Nurse (CHPN)
Certified Rehabilitation Registered Nurse (CRRN)
Registered Nurse-Board Certified (RN-BC) in Gerontological Nursing
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.

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

Central line/central venous catheter and PICC line care and maintenance
IV therapy
Total parenteral nutrition (TPN) and peripheral parenteral nutrition (PPN)
None of the above
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 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.

6C.

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.

7A.

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.

No experience
I have a total of 1 to 12 months of experience using an electronic medical record/charting system in my duties as a Registered Nurse.
I have more than 12 months of experience using an electronic medical record/charting system in my duties as a Registered Nurse.
7B.

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.

7C.

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.

8A.

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?

Yes No
8B.

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.

Alameda County Medical Center - Highland Hospital
Alta Bates Summit Medical Center
California Pacific Medical Center
Jewish Home
Kaiser Permanente
Laguna Honda Hospital and Rehabilitation Center
Marin General Hospital
Mills-Peninsula Medical Center
Other
I do not have training in preventing, managing, and de-escalating aggressive incidents in an underserved urban population in a long term care setting.
8C.

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

8D.

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.

8E.

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.

9A.

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
9B.

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

10A.

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
10B.

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

11A.

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
11B.

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.