offical seal
Santa Cruz County Personnel Department
#20-PJ5-DD


Supplemental Questionnaire

Last Name First Name
 

 

                             SUPPLEMENTAL QUESTIONNAIRE


The supplemental questions are designed specifically for this recruitment. Applications without the required supplemental information will be screened out of the selection process.

NOTE: Please answer the question(s) below as completely and thoroughly as possible, as your answer(s) may be used to assess your qualifications for movement to the next step in the recruitment process.

 


1a.

Have you completed a Psychiatric/Mental Health Nurse Practitioner program?
(If no, please answer 1b below)

Yes No
1b.

If you have not completed a Psychiatric/Mental Health Nurse Practitioner (PMHNP) program, are you enrolled in a PMHNP program AND currently in your final year of training?

Yes
No
N/A
2.

Do you possess a current license to practice as a Registered Nurse issued by the California Board of Registered Nursing?

Yes No
3.

Do you possess a current Nurse Practitioner Certificate issued by the California Board of Registered Nursing or enrolled in a Nurse Practitioner program AND currently in your final year of training?

Yes No
4.

Do you possess a current Nurse Practitioner Furnishing Certificate issued by the California Board of Registered Nursing?

Yes No
5.

Do you possess a current Controlled Substance Registration Certificate – Schedules II – V issued by Department of Justice, Drug Enforcement Administration? If yes, please fax a copy to (831) 454-2240 or scan and email to Personnel@santacruzcounty.us.

Yes No
6.

Describe your experience working with electronic health records.

7.

Describe your experience working in a community mental health setting, include the populations you’ve served(e.g. severely mentally ill, transitional age youth, geriatric, forensic, substance abuse, etc.).