All applicants are required to complete the Supplemental Questionnaire as part of the online application process. The questionnaire will be used to 1) assess each candidate's possession of the minimum qualifications; and 2) determine each candidate's score on the Training and Experience Evaluation, as described on the examination announcement.
Responses to items on the Supplemental Questionnaire must be supportedby the information provided on the application. This information is subject to verification. Please be sure to include all relevant education, professional licenses, certifications or registrations and work experience in the respective Education, Professional Licenses/ Certifications/ Registrations, and Employment Record sections of the application.
Resumes are NOT used or reviewed to determine whether you meet the minimum qualifications or to determine your score/rank. A resume should NOT be submitted to substitute for a completed application. If you write “See Resume” on the application or on the Supplemental Questionnaire, your application may be rejected. Verification of experience, licensure, and possession of valid certifications/registrations may be collected at any time.
If you experience technical difficulties, make note of any error messages and contact the Analyst prior to the filing deadline. Responses should be consistent with the information on your employment application and are subject to verification.
PART ONE: EDUCATION, LICENSES, CERTIFICATION AND REGISTRATION QUALIFICATIONS
INSTRUCTIONS FOR QUESTIONS #1 - #7: Please answer all applicable questions by choosing the best response that matches your education, licenses, certifications and registrations.
1.
Do you possess a valid permanent/temporary (including interim permit) California Registered Nurse (RN) License issued by the California Board of Registered Nursing?
As a reminder, all licenses, certifications and registrations must be listed in the "Professional Licenses, Certifications or Registrations" section of your application in order to receive credit for the licenses, certifications and registrations. If you are copying an old application, please take the time to update the appropriate sections before submitting your application.
Yes
No
2.
Do you possess a valid permanent/temporary (including interim permit) California Nurse Practitioner (NP) License issued by the California Board of Registered Nursing?
As a reminder, all licenses, certifications and registrations must be listed in the "Professional Licenses, Certifications or Registrations" section of your application in order to receive credit for the licenses, certifications and registrations. If you are copying an old application, please take the time to update the appropriate sections before submitting your application.
Yes
No
3.
Do you have possession of a current Nurse Practitioner Furnishing license issued by the California Board of Registered Nursing?
As a reminder, all licenses, certifications and registrations must be listed in the "Professional Licenses, Certifications or Registrations" section of your application in order to receive credit for the licenses, certifications and registrations. If you are copying an old application, please take the time to update the appropriate sections before submitting your application.
Yes
No
4.
Which of the following degrees do you possess?
As a reminder, all education must be listed in the “Higher Education” section of your application in order to receive credit for this education. If you are copying an old application, please take the time to update the appropriate sections before submitting your application.
Associate degree in Nursing (ASN/ADN)
Bachelor of Science degree in Nursing (BSN)
Master of Science degree in Nursing (MSN)
PhD., DNP, or Doctorate in Nursing
None of the above
5.
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
As a reminder, all licenses, certifications and registrations must be listed in the "Professional Licenses, Certifications or Registrations" section of your application in order to receive credit for the licenses, certifications and registrations. If you are copying an old application, please take the time to update the appropriate sections before submitting your application.
Yes
No
6.
What Nurse Practitioner Specialization License or Certification do you possess?
As a reminder, all licenses, certifications and registrations must be listed in the "Professional Licenses, Certifications or Registrations" section of your application in order to receive credit for the licenses, certifications and registrations. If you are copying an old application, please take the time to update the appropriate sections before submitting your application.
Acute Care Nurse Practitioner (ACNP)
Adult Geogontology Acute Care Nurse Practitioner (AGACNP)
Adult Gerontology Nurse Practitioner (AGNP)
Adult Nurse Practitioner (ANP)
Emergency Nurse Practitioner (ENP)
Family Nurse Practitioner (FNP)
Occupational Health Nurse Practitioner (OHNP)
Pediatric Nurse Practitioner (PNP)
Psychiatric Mental Health Nurse Practitioner (PMHNP)
Women's Health Nurse Practitioner (WHNP)
Other
None
7.
How much coursework have you completed in Occupational Health?
As a reminder, all education must be listed in the “Higher Education” section of your application in order to receive credit for this experience. If you are copying an old application, please take the time to update the appropriate section before submitting your application.
I have NOT completed any or have completed less than 2 courses in Occupational Health.
I have completed at least 2 courses in Occupational Health.
I have a degree in Occupational Health Nursing.
8.
How much verifiable full-time experience do you have working as a health care provider in Occupational Health? (Full-time experience is equivalent to 40 hours per week.)
As a reminder, all work experience must be listed in the “Employment Record” section of your application in order to receive credit for this experience. If you are copying an old application, please take the time to update the appropriate section before submitting your application.
I do not have any experience or have less than 6 months working as a Registered Nurse or Nurse Practitioner in Occupational Health.
I have at least 6 months (equivalent to 1,000 hours) but less than 12 months (equivalent to 2,000 hours) working as a Registered Nurse or Nurse Practitioner in Occupational Health.
I have at least 12 months (equivalent to 2,000 hours) but less than 18 months (equivalent to 3,000 hours) working as a Registered Nurse or Nurse Practitioner in Occupational Health.
I have at least 18 months (equivalent to 3,000 hours) but less than 24 months (equivalent to 4,000 hours) working as a Registered Nurse or Nurse Practitioner in Occupational Health.
I have at least 24 months (equivalent to 4,000 hours) or more working as a Registered Nurse or Nurse Practitioner in Occupational Health.
PART TWO: TRAINING AND EXPERIENCE EVALUATION
INSTRUCTIONS FOR QUESTIONS #9 - #16
Review the questions first, prepare and save your responses in a word processing document, and then paste them into the online Supplemental Questionnaire.
Be concise but thorough. Ensure that you address all parts of the question. Your written communication skills will be evaluated based on your responses.
Ensure that your responses are sufficiently detailed to assist in evaluating your knowledge, skills and abilities.
Provide your best or highest examples of work.
Answer all questions independently (e.g., do not reference your responses in prior questions). Provide all information requested even if they appear redundant. Do not write “See Application” or “See Resume” as a response.
If you do not have experience that relates to the question(s) below, please enter “N/A” as your response.
9a.
Which of the following valid American Heart Association Cardiopulmonary Resuscitation (CPR) certificates do you possess?
As a reminder, all licenses, certifications and registrations must be listed in the "Professional Licenses, Certifications or Registrations" section of your application in order to receive credit for the licenses, certifications and registrations. If you are copying an old application, please take the time to update the appropriate sections before submitting your application.
Basic Life Support (BLS) for Healthcare Providers
Advanced Cardiovascular Life Support (ACLS)
Advanced Trauma Life Support (ATLS)
Pediatric Advanced Life Support (PALS)
None of the above
9b.
Please provide your name, certificate number, and the expiration date for each of the American Heart Association CPR certificates you selected in Question 9a. If you answered "None of the above" to question 9a., please provide an explanation.
10a.
Do you have possession of a Drug Enforcement Agency (DEA) number to furnish controlled substances?
Yes
No
10b.
If you answered “Yes” to question 10a., please provide your Drug Enforcement Agency (DEA) number to furnish controlled substances. If you answered “No” to question 10a., please type N/A.
11a.
Which of the following electronic medical records software systems do you have experience using?
Invision/LCR
ECW
JIM
EPIC
Cerner
EMAR
ICCA
ISCHTR
Pulse Check
Avatar
Salar
Oaxaca
Other
None
11b.
If you selected "Other" in question 11a., please specify below.
12a.
Which of the following settings have you worked as a Nurse Practitioner?
Occupational Health
Private Outpatient Office
Adult Surgical Center
Adult Community Clinic
Home Health Agency
School/College/University Clinic
Hospital Inpatient Unit
Family Health Center
Long Term Care Facility
HIV Care Clinic
Dermatology
OB/GYN
Other
None
12b.
If you selected "Other" in question 12a., please specify below.
12c.
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 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 "None," please type N/A.
Do not type “See Resume.”
13a.
How much verifiable full-time professional work experience do you have performing activities in Communicable Disease Surveillance in an employee population? Communicable Disease Surveillance refers to contact tracing, monitoring, and follow-up, but not infection control, in an acute care setting. (Full-time experience is equivalent to 40 hours per week.)
I do not have any experience or have less than 6 months performing activities in Communicable Disease Surveillance in an employee population.
I have at least 6 months of experience (equivalent to 1,000 hours) but less than 12 months (equivalent to 2,000 hours) performing activities in Communicable Disease Surveillance in an employee population.
I have at least 12 months of experience (equivalent to 2,000 hours) but less than 18 months (equivalent to 3,000 hours) performing activities in Communicable Disease Surveillance in an employee population.
I have at least 18 months of experience (equivalent to 3,000 hours) but less than 24 months (equivalent to 4,000 hours) performing activities in Communicable Disease Surveillance in an employee population.
I have at least 24 months of experience (equivalent to 4,000 hours) or more performing activities in Communicable Disease Surveillance in an employee population.
13b.
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 13a.
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.”
13c.
Referring to your answers in questions 13a. and 13b., please provide a brief description of your verifiable professional work experience as indicated in questions 13a. and 13b. 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.”
14a.
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 any or have 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 at least 6 months (equivalent to 1,000 hours) but less than 12 months (equivalent to 2,000 hours) of full-time professional, preceptorship, or volunteer experience working as a health care provider serving a diverse urban population.
I have at least 12 months (equivalent to 2,000 hours) but less than 18 months (equivalent to 3,000 hours) of full-time professional, preceptorship, or volunteer experience working as a health care provider serving a diverse urban population.
I have at least 18 months (equivalent to 3,000 hours) but less than 24 months (equivalent to 4,000) of full-time professional, preceptorship, or volunteer experience working as a health care provider serving a diverse urban population.
I have 24 months (equivalent to 4,000 hours) or more of full-time professional, preceptorship, or volunteer experience working as a health care provider serving a diverse urban population.
14b.
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 14a.
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.”
14c.
Referring to your answers in questions 14a. and 14b., please provide a brief description of your verifiable professional work experience as indicated in questions 14a. and 14b. 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.”
15a.
Which of the following Occupational Health Nurse Certifications do you possess?
COHN Certified Occupational Health Nurse
COHN-S Certified Occupational Health Nurse Specialist
OHNP Specialization Training and Certification
OTHER
NONE
15b.
If you selected "Other" in question 15a., please specify below.
15c.
Please provide your certificate number, your name as it appears on your certificate, and the expiration date if any, for all the certificates you selected in question 15a. If you selected "None of the above" in Question 15a., please type N/A.
16a.
Are you certified as a medical examiner with the National Registry of Certified Medical Examiners?
Yes
No
16b.
Please provide your National Registry of Medical Examiners Registry Number. If you answered "No" to question 16a., 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.
Department of Human Resources