Official SealDepartment of Human Resources


#CBT-2322-080574
Supplemental Questionnaire

Last Name
First Name

 

2322 NURSE MANAGER
SPECIALTY: Long Term Care/Geriatric Nursing
SUPPLEMENTAL QUESTIONNAIRE

The purpose of this Supplemental Questionnaire is to determine if you meet the minimum qualifications of a 2322 Nurse Manager in the Long Term Care/Geriatric Nursing 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 (RN) 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.

What is the highest level of education that you have completed?

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
3A.

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
3B.

Please provide your name, Certificate number, and the expiration date for each of the American Heart Association CPR Certificates you selected in Question 3A. If you answered "None of the above" to question 3A, please provide an explanation.

4A.

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

Invision/LCR
ECW
JIM
EPIC
Cerner
EMAR
ISCHTR
Pulse Check
Salar
ICCA
Avatar
Oaxaca
Other
None
4B.

If you selected "Other" in question 4A., please specify below.

5A.

How much verifiable full-time equivalent 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.)

No Experience
Some, but less than 12 Months
12 to 23 Months
24 or more Months
5B.

Please provide the name of the employer(s) and the dates of employment (e.g. MM/YYYY – MM/YYYY) where you obtained your verifiable work experience as indicated in question 5A.

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.”

6A.

How much verifiable full-time equivalent work experience do you have as a Registered Nurse in a long term care facility, rehabilitation, or acute care hospital within the last five (5) years? (Full-time experience is equivalent to 40 hour per week.)

No Experience
Some, but less than 12 Months
12 to 23 Months
24 to 35 Months
36 to 47 Months
48 to 59 Months
60 or more Months
6B.

Please provide the name of the employer(s) and the dates of employment (e.g. MM/YYYY – MM/YYYY) where you obtained your verifiable work experience as indicated in question 6A.

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.”

6C.

Referring to your answers in questions 6A. and 6B., please provide a brief description of your verifiable work experience as indicated in questions 6A. and 6B. 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.”

7A.

How much verifiable full-time equivalent work experience do you have working at a certified rehabilitation service - either acute or skilled nursing? (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
7B.

Please provide the name of the employer(s) and the dates of employment (e.g. MM/YYYY – MM/YYYY) where you obtained your verifiable work experience as indicated in question 7A.

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.”

7C.

Referring to your answers in questions 7A. and 7B., please provide a brief description of your verifiable work experience as indicated in questions 7A. and 7B. 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.”

8A.

How much verifiable full-time equivalent work experience do you have working with patients who have psychiatric diagnoses? (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
8B.

Please provide the name of the employer(s) and the dates of employment (e.g. MM/YYYY – MM/YYYY) where you obtained your verifiable work experience as indicated in question 8A.

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.”

8C.

Referring to your answers in questions 8A. and 8B., please provide a brief description of your verifiable work experience as indicated in questions 8A. and 8B. 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.”

9A.

Which of the following Certificates do you possess?

Director of Nursing in LTC Certification Program: (DON-CLTC)
RN in Long Term Care Certification Program: (RN-CLTC)
RN-BC Gerontilogical Nursing issued by (ANCC)
Other
None of the above
9B.

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

9C.

Please provide your Certificate number, your name as it appears on your Certificate, and the expiration date, if any, for each of the Certificates you selected in question 9A. If you selected "None of the above" in Question 9A., please type N/A.

 

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.