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Human Capital Management
#200330-Y12C-H02


Supplemental Questionnaire

Last Name First Name
 
 

Do you have a valid Oklahoma license as a registered nurse as approved by the Oklahoma Board of Nursing or, Registered Nurse License recognized by the Enhanced Nurse Licensure Compact (eNLC)?

Yes No
 

Do you have any of the following?

two (2) years of professional nursing experience, INCLUDING one (1) year in a field of nursing appropriate to the health care setting
none of the above

 
STOP! You have completed the required screening questions for this Job Family.  Please verify you meet the education and experience requirements listed in the job bulletin before completing the following supplemental questionnaire. The questions below will be used for scoring in lieu of a written exam.

1.
What experience do you have assessing the health status of individuals, families or communities?
I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I am familiar with this task or have received some training on it.
I have no experience with this task.
 

Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 

2.
What experience do you have developing nursing care plans and implementing appropriate nursing interventions?
I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I am familiar with this task or have received some training on it.
I have no experience with this task.
 

Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 

3.
What experience do you have evaluating and determining health resources necessary to meet individual, family or community needs?
I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I am familiar with this task or have received some training on it.
I have no experience with this task.
 
Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 
4.
I have provided professional nursing care in an assigned:  (Check all that apply.)
hospital.
unit.
clinic.
home.
school.
nursing home.
hospice.
other setting.
 

Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 

5.
What experience do you have educating others about the principles of disease prevention?
I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I am familiar with this task or have received some training on it.
I have no experience with this task.
 

Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 

6.
What experience do you have assuring quality health care through record review, peer review or direct observation?
I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I am familiar with this task or have received some training on it.
I have no experience with this task.
 
Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 
7.
What experience do you have in delegation of duties?
I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I am familiar with this task or have received some training on it.
I have no experience with this task.
 
Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 
8.
Check all of the following certifications you have that are current. 
Basic Life Support (BLS)
Advanced Cardiac Life Support (ACLS)
Pediatric Advanced Life Support (PALS)
I am not current on the certifications listed.
 

Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 

9.
What experience do you have directing the work of other employees in the medical field?
I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I am familiar with this task or have recieved some trianing on it.
I have no experience with this task.
 
Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 
10.
What experience do you have doing follow-up or case management with communicable disease or infectious disease?
I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I am familiar with this task or have received some training on it.
I have no experience with this task.
 
Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 
11.
I have experience with the following nursing skills:  (Check all that apply.)
Immunizations
Case Management
Wound care
Critical care
Handling lab specimens
Acute care
Pediatrics
Mental Health
 
Please list the employer and job title where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below. 

 

Please make sure that you attach all requested documents to your application, if requested.  Resumes should be attached to the "Resume" tab and any other requested documents to the "Other" tab.