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#CCT-2320-900421
Supplemental Questionnaire

Last Name
First Name

 

2320 REGISTERED NURSE
SPECIALTY: CORRECTIONAL FACILITY/JAIL HEALTH SERVICES
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 before the filing deadline. Responses should be consistent with the information on your employment application and are subject to verification.

 

PART ONE: EXPERIENCE AND LICENSE QUALIFICATIONS

 

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


1.

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, 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 licenses, certifications and registrations you are about to describe in the "Professional Licenses, Certifications or Registrations" section of your application, you will not 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.

Yes No
2.

Do you have at least SIX months (equivalent to 1,000 hours) of experience working as a Registered Nurse in a correctional, acute care or skilled nursing setting WITHIN THE LAST THREE YEARS?

As a reminder, all work experience must be listed in the application in order to be considered in review of Minimum Qualifications. If you do not include the work experience you are about to describe in the “Employment Record” section of your application, you will not 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.

Yes.
Partially. I have some but NOT six months of experience working as a Registered Nurse in a correctional, acute care or skilled nursing setting within the last three years.
No. All of my work experience as a Registered Nurse in a correctional, acute care or skilled nursing setting occurred more than three years ago.
No. I do not have at least six months of experience as a Registered Nurse in a correctional, acute care or skilled nursing setting.

 

PART TWO: TRAINING AND EXPERIENCE EVALUATION

INSTRUCTIONS FOR QUESTIONS #3 - #11

 

  • 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.

3A.

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

I have worked 6 months or less as a Registered Nurse in a correctional facility setting.
I have a total of 7 to 12 months of experience as a Registered Nurse in a correctional facility setting.
I have a total of 13 to 18 months of experience as a Registered Nurse in a correctional facility setting.
I have more than 18 months of experience as a Registered Nurse in a correctional facility setting.
3B.

Please indicate the total amount of experience you have working as a Registered Nurse in an acute care or skilled nursing setting.

I have worked 6 months or less as a Registered Nurse in an acute care or skilled nursing setting.
I have a total of 7 to 12 months of experience as a Registered Nurse in an acute care or skilled nursing setting.
I have a total of 13 to 18 months of experience as a Registered Nurse in an acute care or skilled nursing setting.
I have more than 18 months of experience as a Registered Nurse in an acute care or skilled nursing 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 in a correctional, acute care or skilled nursing 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 as a Registered Nurse in these areas, type N/A.

3D.

Please provide a brief description of your work experience as a Registered Nurse in a correctional, acute care, or skilled nursing 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.

Do you have training in correctional facility health policy and procedures, including training in correctional facility security procedures?

Yes No
4B.

If you have training in correctional facility health policy and procedures, including training in correctional facility security procedures, where did you obtain your training? Select all that apply.

Alameda County - Glenn E. Dyer Detention Facility
Alameda County - Santa Rita Jail
California Health Care Facility, Stockton
Contra Costa County Detention Facilities (Martinez, West County, Marsh Creek)
Folsom State Prison, Healthcare Services
Marin County Jail
San Francisco Department of Public Health, Jail Health Services
San Quentin State Prison
Santa Clara County Jail
Other correctional/detention facility
I do not have training in correctional facility policy and procedures, including training in correctional facility security procedures.
4C.

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

4D.

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 correctional facility health policy and procedures, including training in correctional facility security procedures.

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.

4E.

Please provide a brief description of the training in correctional facility health policy and procedures, including training in correctional facility security procedures you received. If you do not have experience in this area, type N/A.

5A.

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) or higher (e.g., PhD in Nursing)
None of the above
5B.

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

6A.

Do you possess a valid Advanced Cardiovascular Life Support (ACLS) course completion card/certificate issued by the American Heart Association?

Yes No
6B.

If you answered "Yes" to the above question, please provide your name as it appears on your course completion card/certificate, the issue date, and the renewal date. If you answered "No", type N/A and continue to the next question. 

7A.

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

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.

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. Include in your answer the name of the specific electronic medical record/charting system you used. Also include 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.

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
8B.

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

9A.

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
9B.

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

10A.

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
10B.

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

11A.

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.)

I do not have any experience or have less than 6 months of experience working as a Registered Nurse in a general acute care hospital.
I have at least 6 months (equivalent to 1,000 hours) but less than 12 months (equivalent to 2,000 hours) working as Registered Nurse in a general acute care hospital.
I have at least 12 months (equivalent to 2,000 hours) of experience but less than 18 months of experience (equivalent to 3,000 hours) working as Registered Nurse in a general acute care hospital.
I have at least 18 months of experience (equivalent to 3,000 hours) but less than 24 months of experience (equivalent to 4,000 hours) working as Registered Nurse in a general acute care hospital.
I have 24 months of experience (equivalent to 4,000 hours) or more working as a Registered Nurse in a general acute care hospital.
11B.

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.

11C.

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."

 

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.