Department of Human Resources

2320 REGISTERED NURSE

SPECIALTY: [General] - Medical Surgical, Perioperative, and Psychiatric Training

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 QUESTION #1: 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?

PART TWO: TRAINING AND EXPERIENCE EVALUATION

INSTRUCTION FOR QUESTIONS #2 - #13:

• 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 nursing area(s) you are willing to work in. You may select more than one.

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.

Do you possess at least one valid certification or certificate in a nursing specialty?

Please list the name of the valid certification(s)/certificate(s) you possess and the name of the agency(s) that issued them. If applicable, include the expiration date.

If you do not possess any valid certifications/certificates in a nursing area, type N/A.

Please select the nursing area in which you have successfully completed at least 120 hours of a preceptorship or internship within the last twelve (12) months. 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 preceptorship or internship you selected above.

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 preceptorship or internship experience. Include in your answer your specific role, primary duties and responsibilities, and the total number of preceptorship or internship hours you completed. If you do not have experience in these areas, type N/A.

Please indicate the total amount of experience you have working as a Registered Nurse in an acute care 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 in an acute 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 experience in this area, type N/A.

Please provide a brief description of your work experience as a Registered Nurse in an acute care setting. 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.

Please indicate the total amount of experience you have working as a Registered Nurse in an ambulatory care 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 in an ambulatory 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 experience in this area, type N/A.

Please provide a brief description of your work experience as a Registered Nurse in an ambulatory care setting. 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.

Please indicate the total amount of experience you have working as a Registered Nurse in a long term care/rehabilitation 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 in a long term care/rehabilitation 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 this area, type N/A.

Please provide a brief description of your work experience as a Registered Nurse in long term care/rehabilitation setting. 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 experience using electronic medical records software such as Invision in your duties as a Registered Nurse?

If you have experience using electronic medical records software in your duties as a Registered Nurse, 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 experience using electronic medical records software in your duties as a Registered Nurse.

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 electronic medical records software in your duties as a Registered Nurse. 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.

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 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."

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.)

Laguna Honda Hospital (LHH) is a skilled nursing and rehabilitation center providing therapeutic care for seniors and adults with disabilities. LHH will open a new Long Term Care Training Program soon. Please indicate your interest by selecting a response.