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#CCT-2320-900406
Supplemental Questionnaire

Last Name
First Name

 

2320 REGISTERED NURSE
SPECIALTY: QUALITY MANAGEMENT
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 Quality Management 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 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?

Yes.
Partially. I have at least two years 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 some but NOT six months 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.
Partially. I have some, but NOT two years 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 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.
No. All of my work experience as a Registered Nurse in an acute care hospital, clinic, home health agency or other health setting AND/OR all of my work experience 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 occurred more than three years ago.
No. I do not have at least two years of work experience as a Registered Nurse in an acute care hospital, clinic, home health agency or other health setting AND I do not have at least six months of experience 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.
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 this area, type N/A.

Note: If you do NOT possess a minimum of 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 AND a minimum of 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, please still provide the information requested above 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 this area, type N/A.

3A.

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.

No experience
I have worked 24 months or less as a Registered Nurse in an acute care hospital, clinic, home health agency or other health setting.
I have a total of 25 to 36 months of experience working as a Registered Nurse in an acute care hospital, clinic, home health agency or other health setting.
I have a total of 37 to 48 months of experience working as a Registered Nurse in an acute care hospital, clinic, home health agency or other health setting.
I have more than 48 months of experience working as a Registered Nurse in an acute care hospital, clinic, home health agency or other health setting.
3B.

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.

3C.

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.

4A.

Please select the highest level of education you have completed.

Associate degree in Nursing (ASN/ADN)
Bachelor's degree in any field (BA/BS)
Bachelor of Science degree in Nursing (BSN)
Master of Science degree in Nursing (MSN) or in a related field
None of the above
4B.

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

5A.

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

Nursing Specialty certification
Patient Safety certification
Quality/Process Improvement certification
Regulatory certification
Risk Management certification
None of the above
5B.

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.

6A.

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

No experience
I have worked 6 months or less in Quality Improvement and/or Risk Management in a medical/healthcare setting.
I have a total of 7 to 12 months of experience working in Quality Improvement and/or Risk Management in a medical/healthcare setting.
I have a total of 13 to 18 months of experience working in Quality Improvement and/or Risk Management in a medical/healthcare setting.
I have more than 18 months of experience working in Quality Improvement and/or Risk Management in a medical/healthcare setting.
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 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.

6C.

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.

7A.

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

Yes No
7B.

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.

7C.

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.

8A.

Have you participated in a Lean Workshop? 

Yes No
8B.

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.

8C.

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

9A.

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?

Yes No
9B.

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.

Alameda County Medical Center - Highland Hospital
Alta Bates Summit Medical Center
California Pacific Medical Center
Kaiser Permanente
Laguna Honda Hospital and Rehabilitation Center
Marin General Hospital
Mills-Peninsula Medical Center
Saint Francis Memorial Hospital
San Francisco General Hospital and Trauma Center
Other
I do not have experience using electronic medical records software in my duties as a Registered Nurse.
9C.

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

9D.

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.

9E.

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.

10A.

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
10B.

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

11A.

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
11B.

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

12A.

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
12B.

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.