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#CBT-2312-902508
Supplemental Questionnaire

Last Name
First Name

 

2312 Licensed Vocational Nurse

SUPPLEMENTAL QUESTIONNAIRE

The purpose of this Supplemental Questionnaire is to determine if you meet the minimum qualifications of a 2312 Licensed Vocational Nurse, and to determine your knowledge, skills, and abilities in job-related areas that have been identified as critical for satisfactory performance in this classification.

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 or temporary (including an interim permit) Licensed Vocational Nurse license from the State of California?

Yes, I have a valid permanent Licensed Vocational Nurse License from the State of California
Yes, I have a valid temporary (including an interim permit) Licensed Vocational Nurse License from the State of California
No, I do not have a valid permanent or temporary (including an interim permit) Licensed Vocational Nurse License from the State of California
1b.

Please provide your License Number, your name as it appears on your License, and the expiration date of your License. If you answered "No" in question 1a., type N/A.

2.

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

Licensed Vocational Nurse Certificate Program
Associate's Degree - Nursing (ASN) or Vocational Nursing
Bachelor's Degree - Nursing (BSN) or higher
None of the above
3a.

How much verifiable full-time equivalent experience do you have working as a Licensed Vocational Nurse? (Full-time is equivalent to 40 hours per week)

No experience
Less than 1 month
1 to 12 months (Maximum of 2000 hours)
13 to 24 months (Maximum of 4000 hours)
More than 24 months (More than 4000 hours)
3b.

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 work experience as a Licensed Vocational Nurse.

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.”

3c.

Referring to your answer in question 3a. and 3b., please provide a brief description of your experience working as a Licensed Vocational Nurse. 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.”

4a.

What type of setting did you gain your experience as a Licensed Vocational Nurse? You may select more than one. If you answered “No Experience” in question 3a., please select “Not Applicable.”

Acute Care
Ambulatory Clinic
Correctional Facility
Long Term Care
Other
Not Applicable
4b.

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

4c.

Please provide the name of the employer(s) and the dates of employment (e.g. MM/YYYY – MM/YYYY) where you worked in the settings you selected.

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 "Not Applicable" in question 4a., please type N/A.

Do not type “See Resume.”

5a.

Have you worked with electronic medical records (EMR) software?

Yes No
5b.

If you checked "Yes" on question 5a., please specify what electronic medical records (EMR) software you have experience using.  If you checked "No," please enter N/A.

5c.

If you selected "Yes" on Question 5a., please provide the name of the employer(s) and the dates of employment (e.g. MM/YYYY – MM/YYYY) where you used the Electronic Medical Records software that you identified.

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 "No" in question 5a., please type N/A.

Do not type “See Resume.”

6a.

Which one of the following current valid Certificate issued by the American Heart Association (AHA) do you possess?

Basic Life Support (BLS) for health care providers Certificate
Cardiopulmonary Resuscitation (CPR) Certificate
I do not have a valid Certificate from the AHA
6b.

Please provide your Certificate Number, your name as it appears on your Certificate, and the expiration date of your Certificate. If you answered "I do not have a valid Certificate from the AHA" in question 6a., type N/A.

7a.

Do you have an I.V./Blood Withdrawal - Class C LVN License (Licensee is certified in intravenous therapy and blood withdrawal)?

Yes No
7b.

Please provide your License Number, your name as it appears on your License, and the expiration date of your License. If you answered "No" in question 7a., 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.

Yes No