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#CBT-2328-902054
Supplemental Questionnaire

Last Name
First Name

 

2328 NURSE PRACTITIONER
SPECIALTY: CORRECTIONAL FACILITIES
SUPPLEMENTAL QUESTIONNAIRE

The purpose of this Supplemental Questionnaire is to determine if you meet the minimum qualifications of a 2328 Nurse Practitioner in the Correctional Facilities specialty, and to determine your knowledge, skills, and abilities in job-related areas that have been identified as critical for satisfactory performance in this specialty.

Responses to supplemental questionnaire items must be supported by the information provided in the body of your application (i.e. education and training/employment record section) in order to receive appropriate credit, and are 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.

INSTRUCTIONS: Please answer all applicable questions by choosing the best response that matches your education, experience, certifications, licenses, and/or by providing the information requested.


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 Registered Nurse license, and the expiration date of your license.  If you answered “No” to question 1a., please provide an explanation below.

2a.

Do you possess a valid permanent/temporary (including interim permit) California Nurse Practitioner (NP) License issued by the California Board of Registered Nursing?

Yes No
2b.

If you answered “Yes” to question 2a., please provide your California Nurse Practitioner license number, your name as it appears on your Nurse Practitioner license, and the expiration date of your license. If you answered “No” to question 2a., please provide an explanation below.

3a.

Do you have possession of a valid Nurse Practitioner Furnishing license issued by the California Board of Registered Nursing?

Yes No
3b.

If you answered “Yes” to question 3a., please provide your California Nurse Practitioner Furnishing license number, your name as it appears on your California Nurse Practitioner Furnishing license, and the expiration date of your license. If you answered “No” to question 3a., please provide an explanation below.

4a.

Which of the following degrees do you possess? 

Associate degree in Nursing (ASN/ADN)
Bachelor of Science degree in Nursing (BSN)
Master of Science degree in Nursing (MSN)
PhD. or DNP in Nursing
None of the above
4b.

Please provide the name of the school and the major course of study for each of the degrees selected in question 4a.

5a.

Do you have possession of a national board certification, or eligibility, as a Nurse Practitioner issued by one of the following recognized national certifying bodies or organizations?

  • American Academy of Nurse Practitioners (AANP)
  • American Nurses Association – American Nurses Credentialing Center (ANCC)
  • Pediatric Nursing Certification Board
  • National Certification Corporation (NCC) for the Women’s Health Care and Neonatal Nursing Specialties
  • American Association of Critical Care Nurses
Yes No
5b.

What Nurse Practitioner Specialization License or Certification do you possess?

Family Nurse Practitioner (FNP)
Adult Nurse Practitioner (ANP)
Acute Care Nurse Practitioner (ACNP)
Women's Health (WHNP)
Pediatric Nurse Practitioner (PNP)
Psychiatric Nurse Practitioner (PMHNP)
Emergency Nurse Practitioner (ENP)
Adult Gerontology Nurse Practitioner (AGNP)
Other
None
5c.

If you selected "Other" in question 5b., please specify below.

5d.

If you answered "Yes" to question 5a., please type the name of the certificate granting organization, the certificate type, the certificate number, and the expiration date if applicable.
If you answered "No" to question 5a., please provide an explanation below.

6a.

Do you have possession of a Drug Enforcement Agency (DEA) number to furnish controlled substances?

Yes No
6b.

If you answered “Yes” to question 6a., please provide your Drug Enforcement Agency (DEA) number to furnish controlled substances. If you answered “No” to question 6a., please type N/A.

7a.

Which of the following valid American Heart Association Cardiopulmonary Resuscitation (CPR) certificates do you possess?

Basic Life Support (BLS) for Healthcare Providers
Advanced Cardiovascular Life Supported (ACLS)
Pediatric Advanced Life Support (PALS)
None of the above
7b.

Please provide your name, certificate number, and the expiration date for each of the American Heart Association CPR certificates you selected in Question 7a. If you answered "None of the above" to question 7a., please provide an explanation.

8a.

Which of the following electronic medical records software systems do you have experience using?

Invision/LCR
ECW
JIM
EPIC
Cerner
EMAR
ISCHTR
Pulse Check
Avatar
Salar
Oaxaca
Other
None
8b.

If you selected "Other" in question 8a., please specify below.

9a.

Which of the following settings have you worked as a Nurse Practitioner?

Private Outpatient Office
Adult Surgical Center
Adult Community Clinics
Home Health Agencies
School/College/University Clinic
Family Health Center
Long Term Care Facility
Outpatient Specialty Clinic (i.e. Neurology, Oncology, etc.)
Other
None
9b.

If you selected "Other" in question 9a., please specify below.

9c.

Please provide the name of the employer(s) and the dates of employment (e.g. MM/YYYY – MM/YYYY) for each setting you selected in question 9a.

In addition, please list the name of (a) supervisor(s) or manager(s) who can verify the information provided as well as his or her contact information. If you selected "None," please type N/A.

Do not type “See Resume.”

10a.

How much verifiable full-time equivalent professional, preceptorship, or volunteer work experience do you have as a health care provider serving a diverse urban population? (Full-time experience is equivalent to 40 hours per week.)

I do not have full-time professional, preceptorship, or volunteer experience working as a health care provider serving a diverse urban population.
I have some, but less than 6 months of full-time professional, preceptorship, or volunteer experience working as a health care provider serving a diverse urban population.
I have 6 to 11 months of full-time professional, preceptorship, or volunteer experience working as a health care provider serving a diverse urban population.
I have 12 or more months of full-time professional, preceptorship, or volunteer experience working as a health care provider serving a diverse urban population.
10b.

Please provide the name of the employer(s) and the dates of employment (e.g. MM/YYYY – MM/YYYY) where you obtained your experience as indicated in question 10a.

In addition, please list the name of (a) supervisor(s) or manager(s) who can verify the information provided as well as his or her contact information. If you selected that you do not have experience, please type N/A.

Do not type “See Resume.”

11a.

How much verifiable full-time work experience do you have as a Nurse Practitioner working in a correctional setting? (Full-time experience is equivalent to 40 hours per week.)

No Experience
Some, but less than 12 Months
12 to 23 Months
24 to 35 Months
36 or more Months
11b.

Please provide the name of the employer(s) and the dates of employment (e.g. MM/YYYY – MM/YYYY) where you obtained your verifiable full-time equivalent professional work experience as indicated in question 11a.

In addition, please list the name of (a) supervisor(s) or manager(s) who can verify the information provided as well as his or her contact information. If you selected that you do not have experience, please type N/A.

Do not type “See Resume.”

11c.

Referring to your answers in questions 11a. and 11b., please provide a brief description of your verifiable professional work experience as indicated in questions 11a. and 11b. In your answer, include details about your specific role, your primary duties, and your responsibilities. If you do not have experience, please type N/A.

Do not type “See Resume.”

12a.

How much verifiable full-time work experience do you have providing intake and triage services in a correctional facility? (Full-time experience is equivalent to 40 hours per week.)

No Experience
Some, but less than 12 Months
12 to 23 Months
24 to 35 Months
36 or more Months
12b.

Please provide the name of the employer(s) and the dates of employment (e.g. MM/YYYY – MM/YYYY) where you obtained your verifiable full-time equivalent professional work experience as indicated in question 12a.

In addition, please list the name of (a) supervisor(s) or manager(s) who can verify the information provided as well as his or her contact information. If you selected that you do not have experience, please type N/A.

Do not type “See Resume.”

12c.

Referring to your answers in questions 12a. and 12b., please provide a brief description of your verifiable professional work experience as indicated in questions 12a. and 12b. In your answer, include details about your specific role, your primary duties, and your responsibilities. If you do not have experience, please type N/A.

Do not type “See Resume.”

 

CERTIFICATION: 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.