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#CCT-2320-901316
Supplemental Questionnaire

Last Name
First Name

 

2320 REGISTERED NURSE
SPECIALTY: INFORMATICS
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 Informatics 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 possission 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 Question1A, please provide additional information below.

2A.

Which of the special conditions for a 2320 Registered Nurse in the Informatics specialty do you meet in order to qualify for this position?

I have at minimum one (1) year of verifiable experience (equivalent to 2000 hours) as Registered Nurse in Nurse Informatics, which includes the use of information structures, information processes, nursing science, and information technology to support nurses, consumers, patients, the inter-professional health care team, and other stakeholders in their decision making.
I have a Master's degree in Nurse Informatics from a Nurse Informatics training program.
I have at minimum one (1) year of verifiable experience (equivalent to 2000 hours) as Registered Nurse in Nurse Informatics, which includes the use of information structures, information processes, nursing science, and information technology to support nurses, consumers, patients, the inter-professional health care team, and other stakeholders in their decision making, AND I have a Master's degree in Nurse Informatics from a Nurse Informatics training program.
I do not possess any of the above.
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.

If you do not possess a minimum of one (1) year of verifiable experience (equivalent to 2000 hours) as a Registered Nurse in Nurse Informatics, which includes the use of information structures, information processes, nursing science, and information technology to support nurses, consumers, patients, the inter-professional health care team, and other stakeholders in their decision making, please still provide the information requested 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.

2D.

If you have a Master's degree in Nurse Informatics from a Nurse Informatics training program, please provide the university where you obtained the Nurse Informatics degree and the date you obtained the Nurse Informatics degree. If you do not have a Master's degree in Nurse Informatics from a Nurse Informatics training program, please type N/A.

3A.

Please indicate the total amount of experience you have working as a Registered Nurse.

No experience as a Registered Nurse.
I have worked less than 12 months as a Registered Nurse.
I have worked a total of 12 to 35 months as a Registered Nurse.
I have worked 36 or more months as a Registered Nurse.
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.

3C.

Please provide a brief description of your work experience 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.

4A.

Please select the highest level of education you have completed.

Associate degree in Nursing (ASN/ADN)
Associate degree in Nursing (ASN/ADN) and currently enrolled in a BSN program
Bachelor of Science degree in Nursing (BSN)
Master of Science degree in Nursing (MSN)
None of the above
4B.

Please list the school(s) where you obtained your degree(s). If you have an ASN/ADN and are currently enrolled in a BSN program, list the name of the school you are attending. If you do not posess any of the degrees above, type N/A.

5A.

Please select the valid certification(s)/certificate(s) you posess in informatics. You may select more than one.

Certified Associate Health Information Management Systems (CAHIMS)
Certified Professional Health Information Management Systems (CPHIMS)
Registered Nurse-Board Certified (RN-BC) in informatics
None of the above
5B.

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

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

6A.

Please indicate the total amount of experience you have working as a unit based superuser.

No experience in this area.
I have a total of 1 to 23 months of experience working as a unit based superuser.
I have a total of 24 to 35 months of experience working as a unit based superuser.
I have 36 or more months of experience working as a unit based superuser.
6B.

Please indicate the total amount of experience you have working as an Informatics Team Member.

I have no experience in this area.
I have a total of 1 to 23 months of experience working as an Informatics Team Member.
I have a total of 24 to 35 months of experience working as an Informatics Team Member.
I have 36 or more months of experience working as an Informatics Team Member.
6C.

Please indicate the total amount of experience you have working as an Informatics Team Lead.

I have no experience in this area.
I have 1 to 23 months of experience working as an Informatics Team Lead.
I have 24 to 35 months of experience working as an Informatics Team Lead.
I have 36 or more months of experience working as an Informatics Team Lead.
6D.

Please indicate the total amount of experience you have working as an Informatics Project Manager.

I have no experience in this area.
I have 1 to 23 months of experience as an Informatics Project Manager.
I have 24 to 35 months of experience as an Informatics Project Manager.
I have 36 or more months of experience as an Informatics Project Manager.
6E.

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 unit based superuser, Informatics Team Member, Informatics Team Lead and/or Informatics Project Manager.

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.

6F.

Please provide a brief description of your work experience as a unit based superuser, Informatics Team Member, Informatics Team Lead and/or Informatics Project Manager. Include in your answer your specific role and primary duties and responsibilies (e.g. charge nurse). If you do not have experience in these areas, type N/A.

7A.

Please indicate the total amount of experience you have as a Registered Nurse working with a diverse urban population.

I have no experience as a Registered Nurse working with a diverse urban population.
I have a total of 1 to 5 months of experience as a Registered Nurse working with a diverse urban population.
I have a total of 6 to 11 months of experience as a Registered Nurse working with a diverse urban population.
I have 12 months or more of experience as a Registered Nurse working with a diverse urban population.
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 as a Registered Nurse working with a diverse urban population.

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 as a Registered Nurse working with a diverse urban population. Include in your answer the specific location of the diverse urban population you worked with (e.g., San Francisco, CA). 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.