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#CCT-2320-900421
Supplemental Questionnaire

Last Name
First Name

 

2320 REGISTERED NURSE
SPECIALTY: CORRECTIONAL FACILITY/JAIL HEALTH SERVICES
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 Correctional Facility/Jail Health Services 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 experience working as a Registered Nurse in a correctional, acute care or skilled nursing setting WITHIN THE LAST THREE YEARS?

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.
2B.

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 in these areas, type N/A.

Note: If you do NOT possess a minimum of SIX months (equivalent to 1,000 hours) of experience within the last three (3) years as a Registered Nurse in a correctional, acute care or skilled nursing setting, please still provide the information requested above as well as the Registered Nurse experience you do possess.

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.

 

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.