The purpose of this Supplemental Questionnaire is to determine if you meet the minimum qualifications of a 2324 Nursing Supervisor in the Inpatient Services 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.
If you experience technical difficulties, make note of any error messages and contact the Analyst prior to the filing deadline.
INSTRUCTIONS: Please answer all applicable questions by choosing the best response that matches your education, experience, certifications, and licenses by providing the information requested.
1.
What is the highest degree you have obtained in Nursing?
Associate's of Science Degree in Nursing (ASN)
Bachelor's of Science Degree in Nursing (BSN)
Master's of Science Degree in Nursing (MSN) or higher (i.e. PhD.)
No Degree in Nursing
2.
Please identify the highest graduate level degree that you possess from the list of disciplines below. If you do not have a graduate level degree in these disciplines, please select "None of the above."
Master's degree in Nursing
Master's degree in Public Health
Master's degree in Public Administration
Ph.D. degree in Nursing
Ph.D. degree in Public Health
Ph.D. degree in Public Administration
None of the above
3.
Do you possess a valid California Registered Nurse license issued by the California Board of Registered Nursing?
Yes
No
4a.
How much verifiable full-time equivalent experience do you have in a designated Nursing supervisory capacity (nurse manger or designated charge nurse) or administrative leadership/support role, in a Medical-Surgical, Critical Care, Perioperative, Emergency, Psychiatry, Perinatal, or similar inpatient unit in an acute care hospital (a hospital which provides 24 hour inpatient care, including the following basic services: Medical, Nursing, Surgical, Anesthesia, Laboratory, Radiology, Pharmacy and Dietary Services)? (Full-time experience is equivalent to 40 hours per week.)
I do not have any experience in these areas
I have less than 24 months of experience in these areas
I have at least 24 months of experience in these areas
I have between 25 months and 36 months of experience in these areas
I have between 37 months and 48 months of experience in these areas
I have between 49 months and 60 months of experience in these areas
I have more than 60 months of experience in these areas
4b.
In accordance with your response to question 4 above, how many employees do you have experience supervising? Relevant supervisory experience should include, but not be limited to staff development, performance evaluation, and disciplinary processes.
I have experience supervising fewer than 25 employees
I have experience supervising between 25 to 49 employees
I have experience supervising between 50 to 74 employees
I have experience supervising between 75 to 100 employees
I have experience supervising more than 100 employees
5a.
Do you have a valid Cardiopulmonary Resuscitation (CPR) certificate issued by the American Heart Association (AHA)?
Yes
No
5b.
If you answered “Yes” to #5a above, please identify all of the valid AHA CPR certificates that you possess.
Basic Life Support (BLS) for Healthcare Providers
Advanced Cardiovascular Life Support (ACLS)
Pediatric Advanced Life Support (PALS)
Other
6.
Do you possess a valid Certification in Infection Control (CIC) awarded by the Certification Board of Infection Control & Epidemiology, Inc. (CBIC)?
As a reminder, all licenses, certifications and registrations must be listed in the application in order to be considered in review of Minimum Qualifications. If you do not include the licenses, certifications and registrations you are about to describe in the "Professional Licenses, Certifications or Registrations" section of your application, you will not 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
7.
Do you have knowledge and experience in the application of the following federal and state regulatory and/or accreditation standards? If yes, please select all that apply.
The Joint Commission
California Code of Regulations - Title 22
Centers for Medicare & Medicaid Services
Americans with Disabilities Act (ADA)
Equal Employment Opportunity Commission (EEOC)
I do not have knowledge or experience in these areas.
I understand that checking this box will serve as my electronic signature. I certify that I am the author of this form and all information presented is true and based upon my work education and/or work experience. I understand that prior to an appointment, I may be required to provide written verification of any of the information provided above and, during the probationary period, I may be required by the hiring department to participate in (a) performance test(s). I further understand that any false, incomplete, or incorrect statement may result in disqualification, dismissal, or termination of employment from the City and County of San Francisco.
Department of Human Resources