Department of Human Resources

2320 REGISTERED NURSE
SPECIALTY: QUALITY MANAGEMENT
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.

PART ONE: EXPERIENCE, LICENSES AND CERTIFICATION QUALIFICATIONS

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

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, all 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.

Do you have at least TWO years (equivalent to 4,000 hours) of experience working as a Registered Nurse in an acute care hospital, clinic, home health agency or other health setting WITHIN THE LAST THREE YEARS

AND 

at least SIX months (equivalent to 1,000 hours) of experience working in Quality Improvement and/or Risk Management in a medical/healthcare setting or home health agency utilizing the OASIS and/or coordinating or participating in home health QI activities 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 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.

PART TWO: TRAINING AND EXPERIENCE EVALUATION

INSTRUCTIONS FOR QUESTIONS #3 - #12

• 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.

Please indicate the total amount of experience you have working as a Registered Nurse in an acute care hospital, clinic, home health agency or other health 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 hospital, clinic, home health agency or other 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.

Please provide a brief description of your work experience as a Registered Nurse in an acute care hospital, clinic, home health agency or other 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.

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.

Please select the valid certification(s) you possess. You may select more than one.

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

If you do not possess any of the certifications listed above, type N/A.

Please indicate the total amount of experience you have working in Quality Improvement and/or Risk Management in a medical/healthcare 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 working in Quality Improvement and/or Risk Management in a medical/healthcare 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.

Please provide a brief description of your work experience in Quality Improvement and/or Risk Management in a medical/healthcare 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.

Have you successfully completed a quality improvement or leadership training program?

Please provide the name of your Employer(s)/Hospital(s)/Clinic(s) and the dates (e.g., MM/YYYY - MM/YYYY) you completed the quality improvement or leadership 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 did not receive training in this area, type N/A.

Please provide a brief description of the quality improvement or leadership training you received. Include the name of the specific training program you completed. If you do not have training in these areas, type N/A.

Have you participated in a Lean Workshop? 

Please provide the name of your Employer(s)/Hospital(s)/Clinic(s) and the dates (e.g., MM/YYYY - MM/YYYY) you participated in a Lean Workshop.

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 have not participated in a Lean Workshop, type N/A.

Please provide a brief description of the Lean Workshop you participated in. If you did not participate in a Lean Workshop, type N/A.

Do you have experience using electronic medical records software such as Emergency Department Information System (EDIS), Intensive Care Information System (ICIS), or Lifetime Clinical Record (LCR) 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.