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#CCT-2320-900425
Supplemental Questionnaire

Last Name
First Name

 

2320 REGISTERED NURSE
SPECIALTY: HOME HEALTH CARE NURSING
SUPPLEMENTAL QUESTIONNAIRE

 

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 supported by 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. Responses should be consistent with the information on your employment application and are subject to verification.

 

PART ONE: EXPERIENCE, LICENSES AND CERTIFICATION QUALIFICATIONS

 

INSTRUCTIONS FOR QUESTIONS #1 - #2: Please answer all applicable questions by choosing the best response that matches your work experience, licenses and certifications.


1.

Do you possess a valid permanent/temporary (including interim permit) California Registered Nurse License issued by the California Board of Registered Nursing?

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 education, 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
2.

Which of the special conditions for a 2320 Registered Nurse in the Home Health Care Nursing specialty do you meet in order to qualify for this position?

As a reminder, all work experience must be listed in the application in order to be considered in review of Minimum Qualifications. If you do not include the experience you are about to describe in the “Employment Record” section of your application, you will not receive credit for this work experience. If you are copying an old application, please take the time to update the appropriate section before submitting your application.

I have at minimum one (1) year of verifiable experience (equivalent to 2,000 hours) within the last three (3) years as a Registered Nurse in a licensed home health agency.
I have at minimum two (2) years of verifiable experience (equivalent to 4,000 hours) within the last three (3) years as a Registered Nurse in an acute care setting.
I do not possess any of the above.

 

PART TWO: TRAINING AND EXPERIENCE EVALUATION

 

INSTRUCTIONS FOR QUESTIONS #3 - #12

 

  • 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.

3A.

Please select the highest level of education you have completed.

Associate degree in Nursing (ASN/ADN)
Bachelor of Science degree in Nursing (BSN)
Master of Science degree in Nursing (MSN)
None of the above
3B.

Please list the school(s) where you obtained your degree(s). If you do not possess any of the degrees above, type N/A.

4A.

Please select the valid certification(s)/certificate(s) you possess. You may select more than one.

Certification for Adult, Pediatric and Neonatal Critical Care Nurses (CCRN)
Certified medical-surgical (CMSRN)
Home Health Case Manager certificate
Home Health Nurse certificate
Registered Nurse-Board Certified (RN-BC)
None of the above
4B.

Please list the name of the agency(s) that issued the certification(s)/certificate(s) you possess. If applicable, include the expiration date.

If you do not possess any of the certifications/certificates listed above, type N/A.

5A.

Please indicate the total amount of experience you have working as a Registered Nurse in a licensed home health agency.

No experience
I have worked 12 months or less as a Registered Nurse in a licensed home health agency.
I have a total of 13 to 24 months of experience working as a Registered Nurse in a licensed home health agency.
I have a total of 25 to 36 months of experience working as a Registered Nurse in a licensed home health agency.
I have more than 36 months of experience working as a Registered Nurse in a licensed home health agency.
5B.

Please provide the name of your Employer(s)/Hospital(s)/Clinic(s) and the dates (e.g., MM/YYYY - MM/YYYY) you obtained your experience as a Registered Nurse in a licensed home health agency.

In addition, please list the name of a supervisor or manager who can verify the information you provided as well as his or her contact information. If you do not have experience in this area, type N/A.

5C.

Please provide a brief description of your work experience as a Registered Nurse in a licensed home health agency. Include in your answer your specific role and primary duties and responsibilities (e.g., charge nurse). If you do not have experience in this area, type N/A.

6A.

Please indicate the total amount of experience you have working as a Registered Nurse in an acute care setting.

No experience
I have worked 24 months or less as a Registered Nurse in an acute care setting.
I have a total of 25 to 36 months of experience working as a Registered Nurse in an acute care setting.
I have a total of 37 to 48 months of experience working as a Registered Nurse in an acute care setting.
I have more than 48 months of experience working as a Registered Nurse in an acute care setting.
6B.

Please provide the name of your Employer(s)/Hospital(s)/Clinic(s) and the dates (e.g., MM/YYYY - MM/YYYY) you obtained your experience as a Registered Nurse in an acute care setting.

In addition, please list the name of a supervisor or manager who can verify the information you provided as well as his or her contact information. If you do not have experience in this area, type N/A.

6C.

Please provide a brief description of your work experience as a Registered Nurse working in an acute care setting. Include in your answer your specific role and primary duties and responsibilities (e.g., charge nurse). If you do not have experience in this area, type N/A.

7A.

Please indicate the total amount of experience you have as a Registered Nurse using the Outcome and Assessment Information Set (OASIS).

No Experience
I have 12 months or less of experience as a Registered Nurse using the Outcome and Assessment Information Set (OASIS).
I have more than 12 months of experience as a Registered Nurse using the Outcome and Assessment Information Set (OASIS).
7B.

Please provide the name of your Employer(s)/Hospital(s)/Clinic(s) and the dates (e.g., MM/YYYY - MM/YYYY) you obtained your experience as a Registered Nurse using the Outcome and Assessment Information Set (OASIS).

In addition, please list the name of a supervisor or manager who can verify the information you provided as well as his or her contact information. If you do not have experience in this area, type N/A.

7C.

Please provide a brief description of your work experience as a Registered Nurse using the Outcome and Assessment Information Set (OASIS). Include in your answer your specific role and primary duties and responsibilities (e.g., charge nurse). If you do not have experience in this area, type N/A.

8A.

Please indicate the total amount of experience you have as a Registered Nurse working with an underserved, diverse urban population.

No experience
I have 12 months or less of experience as a Registered Nurse working with an underserved, diverse urban population.
I have more than 12 months of experience as a Registered Nurse working with an underserved, diverse urban population.
8B.

Please provide the name of your Employer(s)/Hospital(s)/Clinic(s) and the dates (e.g., MM/YYYY - MM/YYYY) you obtained your experience as a Registered Nurse working with an underserved, diverse urban population

In addition, please list the name of a supervisor or manager who can verify the information you provided as well as his or her contact information. If you do not have experience in this area, type N/A.

8C.

Please provide a brief description of your work experience as a Registered Nurse working with an underserved, diverse urban population. Include in your answer your specific role and primary duties and responsibilities (e.g., charge nurse) and the specific location of the underserved, diverse urban population. If you do not have experience in this area, type N/A.

9A.

Do you have experience using point of care documentation software such as Encore in your duties as a Registered Nurse?

Yes No
9B.

If you have experience using point of care documentation software in your duties as a Registered Nurse, where did you obtain this experience? Select all that apply.

Alameda County Medical Center - Highland Hospital
Alta Bates Summit Medical Center
California Pacific Medical Center
Kaiser Permanente
Laguna Honda Hospital and Rehabilitation Center
Marin General Hospital
Mills-Peninsula Medical Center
Saint Francis Memorial Hospital
Other
I do not have experience using point of care documentation software.
9C.

If you selected "Other", please specify in the space below. Otherwise, type N/A.

9D.

Please provide the name of your Employer(s)/Hospital(s)/Clinic(s) and the dates (e.g., MM/YYYY - MM/YYYY) you obtained your experience using point of care documentation software.

In addition, please list the name of a supervisor or manager who can verify the information you provided as well as his or her contact information. If you do not have experience in this area, type N/A.

9E.

Please provide a brief description of your work experience as a Registered Nurse using point of care documentation software. Include in your answer the name of the point of care documentation software you used. Also include your specific role and primary duties and responsibilities (e.g., charge nurse). If you do not have experience in this area, type N/A.

10A.

Can you speak any of the following languages? You may select more than one.

Arabic
American Sign Language
Burmese
Cambodian
Chinese (Cantonese)
Chinese (Other)
Chinese (Mandarin)
Japanese
Korean
Laotian
Russian
Spanish
Tagalog (Philippines)
Vietnamese
Other
None of the above
10B.

If you selected "Other", please specify in the space below. Otherwise, type N/A.

11A.

Can you read any of the following languages? You may select more than one.

Arabic
American Sign Language
Burmese
Cambodian
Chinese (Cantonese)
Chinese (Other)
Chinese (Mandarin)
Japanese
Korean
Laotian
Russian
Spanish
Tagalog (Philippines)
Vietnamese
Other
None of the above
11B.

If you selected "Other", please specify in the space below. Otherwise, type N/A.

12A.

Can you write in any of the following languages? You may select more than one.

Arabic
American Sign Language
Burmese
Cambodian
Chinese (Cantonese)
Chinese (Other)
Chinese (Mandarin)
Japanese
Korean
Laotian
Russian
Spanish
Tagalog (Philippines)
Vietnamese
Other
None of the above
12B.

If you selected "Other", please specify in the space below. Otherwise, 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.