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#CCT-2320-900420
Supplemental Questionnaire

Last Name
First Name

 

2320 REGISTERED NURSE
SPECIALTY: PSYCHIATRIC 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 Psychiatric 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 Psychiatric 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 Psychiatric Unit/Clinic and/or Mental Health Center.
I have completed a senior preceptorship in psychiatric nursing.
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 Psychiatric Unit/Clinic and/or Mental Health Center OR if you have not completed a senior preceptorship in psychiatric nursing, 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.

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.

Clinical Nurse Leader (CNL) certification
Registered Nurse-Board Certified (RN-BC) in Psychiatric-Mental Health
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.

5A.

Please indicate the total amount of experience you have working as a Registered Nurse in a Psychiatric Unit/Clinic and/or Mental Health Center.

No experience
I have 12 months or less of experience as a Registered Nurse in a Psychiatric Unit/Clinic and/or Mental Health Center.
I have a total of 13 to 24 months of experience working as a Registered Nurse in a Psychiatric Unit/Clinic and/or Mental Health Center.
I have a total of 25 to 36 months of experience working as a Registered Nurse in a Psychiatric Unit/Clinic and/or Mental Health Center.
I have more than 36 months of experience working as a Registered Nurse in a Psychiatric Unit/Clinic and/or Mental Health Center.
5B.

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 Psychiatric Unit/Clinic and/or Mental Health Center.

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.

5C.

Please provide a brief description of your work experience as a Registered Nurse in a Psychiatric Unit/Clinic and/or Mental Health Center. 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.

6A.

Please indicate the total amount of experience you have working as a Registered Nurse in an inpatient psychiatric unit.

No experience
I have a total of 1 to 12 months of experience working as a Registered Nurse in an inpatient psychiatric unit.
I have a total of 13 to 24 months of experience working as a Registered Nurse in an inpatient psychiatric unit.
I have a total of 25 to 36 months of experience working as a Registered Nurse in an inpatient psychiatric unit.
I have more than 36 months of experience working as a Registered Nurse in an inpatient psychiatric unit.
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 as a Registered Nurse in an inpatient psychiatric unit.

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 your work experience as a Registered Nurse in an inpatient psychiatric unit. 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.

7A.

Please indicate the total amount of experience you have as a Registered Nurse working with populations with substance use disorders.

No experience
I have a total of 1 to 12 months of experience as a Registered Nurse working with populations with substance use disorders.
I have more than 12 months of experience as a Registered Nurse working with populations with substance use disorders.
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 as a Registered Nurse working with populations with substance use disorders.

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 experience as a Registered Nurse working with populations with substance use disorders. 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 psychiatric de-escalation such as Psychiatric Rapid Response Training (PRRT)?

Yes No
8B.

If you have training in psychiatric de-escalation, where did you obtain this training? Select all that apply.

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 training in psychiatric de-escalation.
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 psychiatric de-escalation training.

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.

8E.

Please provide a brief description of the psychiatric de-escalation training you received. If you do not have experience 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.